Foot outcomes from the Chingford cohort study of
Foot outcomes from the Chingford cohort study of
Foot outcomes from the Chingford cohort study of
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The <strong>Chingford</strong> 1000<br />
Womens’ <strong>study</strong>:<br />
Epidemiology <strong>of</strong> <strong>Foot</strong> OA<br />
Dr Cathy Bowen<br />
Pr<strong>of</strong> Nigel Arden<br />
Pr<strong>of</strong> Mike Doherty<br />
Dr Wendy Dreschler<br />
Dr David Stephenson
<strong>Foot</strong> & Lower Limb Research<br />
I<br />
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s<br />
h<br />
i<br />
p<br />
RA<br />
OA<br />
• FeeTURA<br />
• Ultrasound<br />
• MRI<br />
• Biomechanics<br />
• Pharmacology<br />
• <strong>Chingford</strong><br />
• Coast<br />
• Radiography<br />
• Biomechanics<br />
1. Cohort studies 2. Imaging 3. Function 4. Intervention
The <strong>Chingford</strong> Womens Study<br />
A well-established <strong>cohort</strong> <strong>of</strong> middle aged women<br />
http://www.chingford<strong>study</strong>.org.uk)
The <strong>Chingford</strong> Womens Study<br />
• Established in 1989 as a retrospective case-control <strong>study</strong> to<br />
determine prevalence rates <strong>of</strong> osteoarthritis (OA) and<br />
osteoporosis (OP) in middle-aged women in <strong>the</strong> general<br />
population, and to assess a number <strong>of</strong> known risk factors and<br />
<strong>the</strong>ir associations with <strong>the</strong>se two diseases.<br />
• It has since become a prospective population-based longitudinal<br />
<strong>cohort</strong> <strong>of</strong> women seen annually and described in detail.<br />
• It is listed by <strong>the</strong> NIHR as an important epidemiological resource<br />
and one <strong>of</strong> <strong>the</strong> few such <strong>cohort</strong>s with wide-ranging<br />
musculoskeletal data
1989 year 1 visit<br />
1,003 women<br />
1994 year 5 visit<br />
863 women<br />
1989<br />
1,353 women invited<br />
6 died<br />
66 moved away<br />
278 declined/did not respond<br />
15 died<br />
40 moved away<br />
44 dropped out<br />
41 did not attend<br />
1999 year 10 visit<br />
811 women<br />
2004 year 15 visit<br />
657 women<br />
2009 year 20 visit<br />
516 women<br />
40 died<br />
61 moved away<br />
80 dropped out<br />
11 did not attend<br />
99 died<br />
75 moved away<br />
85 dropped out<br />
87 did not attend<br />
158 died<br />
68 moved away<br />
125 dropped out<br />
136 did not attend<br />
Goulston LM, Kiran A, Javaid MK, Soni A, White KM, Hart DJ, Spector TD, Arden NK. Does obesity<br />
predict knee pain over fourteen years in women, independently <strong>of</strong> radiographic changes? Arthritis<br />
Care Res (Hoboken). 2011, Oct;63(10):1398-406.
The <strong>Chingford</strong> Womens Study<br />
At year 6, 872 participants returned for re-assessment (87% response rate) with a mean age:<br />
54 years (SD 17.9), height: 161cm (SD 5.9) and weight: 68.7Kg (SD 12.3).<br />
At year 15, 614 participants had returned for reassessment with a mean age <strong>of</strong> 69.2 years (SD<br />
5.8).<br />
At year 20, 516 participants had returned for re-assessment, <strong>the</strong> data for which is still being<br />
analysed.<br />
Radiographs <strong>of</strong> knees were taken at year 5 with 16.9% right and 19.4% left knees defined as<br />
having OA according to <strong>the</strong> K&L scale.<br />
At year 15, this had risen to 39.9% right and 35.7% left knees affected by OA.<br />
At year 20 …… Goulston LM et al (ongoing PhD <strong>the</strong>sis)
The <strong>Chingford</strong> Womens Study<br />
• Knee & Hip radiographs were read by<br />
investigators, using an atlas <strong>of</strong><br />
radiographic features with good<br />
reproducibility [Spector et al 1993;<br />
Hart et al 1994; Hassett et al 2003].<br />
• However, o<strong>the</strong>r than recording <strong>the</strong><br />
presence or not <strong>of</strong> first metatarsophalangeal<br />
(MTP) joint osteophytes and<br />
narrowing and angle <strong>of</strong> hallux valgus,<br />
<strong>the</strong> data has not previously been<br />
analysed with respect to foot OA.
<strong>Foot</strong> OA Study: Background<br />
• Our previous work has shown that older age, female gender and low socioeconomic status are known<br />
risk factors for OA [Arden & Nevitt 2006] .<br />
• In addition, knee OA is particularly associated with being overweight or obese and low activity [Badley<br />
& Ansari 2010] a factor that is set to become a major public health problem over <strong>the</strong> next few decades<br />
[Bitton 2009; Dixon 2009].<br />
• It is <strong>the</strong>se insights that have led us to <strong>the</strong> development <strong>of</strong> more targeted <strong>the</strong>rapeutic approaches and<br />
interventions for <strong>the</strong> management <strong>of</strong> hip and knee pain related to OA (OARSI) [Zhang et al 2007;<br />
Zhang et al 2008; Zhang et al 2009].<br />
• OA occurring within <strong>the</strong> feet, however, is less well understood.<br />
• To our knowledge, <strong>the</strong>re are currently no internationally agreed diagnostic guidelines or treatment<br />
codes specific for foot OA.<br />
• A recent systematic review <strong>of</strong> radiographic definitions <strong>of</strong> foot OA identified very few studies examining<br />
radiographic foot OA such that <strong>the</strong> authors were unable to estimate <strong>the</strong> population prevalence <strong>of</strong><br />
radiographic foot OA [Trivedi et al 2010].<br />
• ‘The clinical assessment <strong>study</strong> <strong>of</strong> <strong>the</strong> foot’ (CASF) <strong>study</strong> proposal is <strong>the</strong> implementation <strong>of</strong> a three year<br />
prospective observational <strong>study</strong> <strong>of</strong> foot pain and foot OA, (Roddy et al 2011). Within <strong>the</strong> CASF <strong>study</strong>,<br />
<strong>the</strong> focus is on investigation <strong>of</strong> participants over 50 years <strong>of</strong> age in <strong>the</strong> general population who have<br />
experienced foot pain i.e. symptomatic OA.
The <strong>Chingford</strong> Womens Study<br />
No<br />
200<br />
150<br />
100<br />
50<br />
3.6%<br />
Number <strong>of</strong> participants<br />
mentioning foot pain<br />
4.8%<br />
15.9%<br />
17.1%<br />
14.9%<br />
18.3%<br />
Numbers are based<br />
on participants<br />
mentioning some<br />
pain in some area<br />
<strong>of</strong> <strong>the</strong>ir foot/feet in<br />
<strong>the</strong> past.<br />
0<br />
3 5 6 8 10 15<br />
Year
<strong>Foot</strong> OA Study: Aims<br />
• The specific aims <strong>of</strong> our research are to develop a detailed<br />
understanding <strong>of</strong> <strong>the</strong> epidemiology, risk factors and<br />
associations <strong>of</strong> OA occurring within <strong>the</strong> feet in <strong>the</strong> general<br />
population at middle and older age.<br />
• An additional aim is to determine <strong>the</strong> lower limb<br />
biomechanical factors associated with radiographic foot<br />
OA.
<strong>Foot</strong> OA Study Design<br />
• The proposed <strong>study</strong> will utilise an observational <strong>cohort</strong><br />
design to investigate a general population who were<br />
recruited with no known lower limb OA or foot pain.
Collaborators<br />
• <strong>Foot</strong> Morf<br />
S<strong>of</strong>tware<br />
analysis<br />
• <strong>Foot</strong><br />
characteristics<br />
Oxford<br />
Pr<strong>of</strong> Nigel Arden<br />
Nottingham<br />
Pr<strong>of</strong> Mike<br />
Doherty<br />
• Clinical foot<br />
assessments<br />
Southampton<br />
Dr Cathy Bowen<br />
East London<br />
Dr Wendy<br />
Dreschler<br />
Dr Daivid<br />
Stephenson<br />
• Lower limb<br />
biomechanics
Comparator sample (The GOAL Study)<br />
• The main focus <strong>of</strong> our proposed <strong>study</strong> is to evaluate<br />
foot OA in a unique general population <strong>cohort</strong> <strong>of</strong><br />
middle aged women.<br />
• The <strong>Chingford</strong> <strong>study</strong>, by design, is representative <strong>of</strong><br />
middle aged women but accepts that men are not<br />
included.<br />
• As a comparator, we propose to fur<strong>the</strong>r investigate<br />
foot characteristics <strong>of</strong> middle aged male<br />
participants in <strong>the</strong> GOAL (Genetics <strong>of</strong><br />
Osteoarthritis and Lifestyle) <strong>study</strong> led by Pr<strong>of</strong>.<br />
Doherty.<br />
• The GOAL <strong>study</strong> included a sample <strong>of</strong> general<br />
population (N= 600) investigated as a case control<br />
‘one <strong>of</strong>f’ <strong>cohort</strong> (non-OA) but with <strong>the</strong> potential for<br />
re-questioning that population regarding foot pain.
Laboratory <strong>study</strong> Subset (n=50)<br />
Gait parameters: hip, knee and ankle<br />
joint motion (sagittal plane);<br />
plantar foot pressures (peak, time<br />
<strong>of</strong> peak, integral peak, mean force,<br />
time <strong>of</strong> footsteps); muscle strength<br />
(gastrocnemius, quadriceps).<br />
Muscle morphology: US measurement<br />
<strong>of</strong> gastrocnemius (cross sectional<br />
area, thickness, width, fascicle<br />
length, pennation angle)<br />
Function: Walking time; timed up &<br />
go; HAQ
To be continued….<br />
Clinical foot<br />
assessments<br />
Radiographic foot<br />
assessment<br />
Lower limb function<br />
assessment<br />
15
Acknowledgements:<br />
We would like to thank all <strong>the</strong> participants <strong>of</strong> <strong>the</strong> <strong>Chingford</strong><br />
Women Study and Pr<strong>of</strong>essor Tim Spector, Dr Deborah Hart<br />
and Dr Alan Hakim and Maxine Daniels for <strong>the</strong>ir time and<br />
dedication and Arthritis Research UK for <strong>the</strong>ir continued<br />
funding support to <strong>the</strong> <strong>study</strong>.<br />
16