Background: Knee osteoarthritis (OA) is the most common form of arthritis in older adults. Knee OA is associated with limitations in physical function. Functional limitations are also associated with another geriatric condition, frailty. Frailty is characterized by reduced strength, endurance and physiological function. Purpose: The primary purpose of this study is to determine if there is a difference in radiographic or symptomatic knee OA severity between non-frail and pre-frail women with knee OA. Secondary objectives include: a) the relationship between radiographic and symptomatic OA severity with serum inflammatory cytokines, and b) if there is a difference in inflammatory cytokines between non-frail and pre-frail women with knee OA. Methods: We included 21 community-dwelling women with knee OA. Frailty was assessed using the Fried Frailty Phenotype. Knee OA severity was characterized by the Kellgren and Lawrence (KL) score and the Knee Injury and Osteoarthritis Outcome Questionnaire (KOOS). Inflammatory cytokines included serum interleukin-6 (IL-6), interleukin-10 (IL-10), tumor necrosis alpha (TNF α) and C reactive protein (CRP). Results: Data from 20 participants (66.1 [9.6] years, BMI 29.7 [4.9] kg/m2, non-frail=55%; pre-frail=45%) were analyzed. Radiographic severity was not different between frailty groups (p= 0.11). There was no difference in symptomatic knee OA severity, measured using the KOOS subscales, between frailty groups (p>0.17). Radiographic OA severity and inflammatory markers were not associated (p>0.30). There was a negative relationship between TNF α and self-reported pain (r=0.26), no relationships between inflammatory cytokines with any other KOOS sub-scales. Lastly, there was no difference in any inflammatory cytokines between non-frail and pre-frail groups. Conclusion: Despite the relatively young age, nearly 50% of our participants were pre-frail. Pre-frailty was unrelated to the severity of the knee OA, or inflammatory cytokines. TNF α may be involved in the experience of pain in these women. While it appears women with knee OA frequently demonstrate pre-frail status, more work is necessary to examine the link between these diseases. / Thesis / Master of Science (MSc) / Arthritis is a chronic disease that has a debilitating effect on the lives of more than 4.6 million Canadians. In 2015, the cumulative economic burden of osteoarthritis was 195.2 billion dollars and is expected to increase significantly in the next two years. Knee osteoarthritis is the most common form of arthritis in older adults. Knee osteoarthritis is associated with increased pain, decreased physical function and decreased quality of life (QOL). In vulnerable older adults increased exhaustion, decreased physical function and muscle loss can increase the risk of developing frailty. Frail older adults are at higher risk of adverse health outcomes such as falls, hospitalization and death. Previous research has shown that older adults with knee OA are at higher risk of developing frailty however, it is not understood what underlying mechanisms increase this risk. This thesis provides fundamental information aimed at understanding potential mechanisms associated with knee osteoarthritis and frailty in women. Our study found that despite their relatively young age, nearly half of the women with knee OA are pre-frail. This data shows that inflammatory cytokines in particular, tumor necrosis factor alpha is related to symptomatic knee osteoarthritis severity in particular, self-reported pain. Overall, early detection of frailty is important when managing this condition. These data suggest that chronic knee pain associated with OA may be a useful trigger for early assessments of frailty in women.

Our aim was to analyse (i) the presence of single nucleotide polymorphisms (SNPs) in the JUN and FOS core promoters in patients with rheumatoid arthritis (RA), knee-osteoarthritis (OA), and normal controls (NC); (ii) their functional influence on JUN/FOS transcription levels; and (iii) their associations with the occurrence of RA or knee-OA. JUN and FOS promoter SNPs were identified in an initial screening population using the Non-Isotopic RNase Cleavage Assay (NIRCA); their functional influence was analysed using reporter gene assays. Genotyping was done in RA (n = 298), knee-OA (n = 277), and NC (n = 484) samples. For replication, significant associations were validated in a Finnish cohort (OA: n = 72, NC: n = 548). Initially, two SNPs were detected in the JUN promoter and two additional SNPs in the FOS promoter in perfect linkage disequilibrium (LD). JUN promoter SNP rs4647009 caused significant downregulation of reporter gene expression, whereas reporter gene expression was significantly upregulated in the presence of the FOS promoter SNPs. The homozygous genotype of FOS promoter SNPs showed an association with the susceptibility for knee-OA (odds ratio (OR) 2.12, 95% confidence interval (CI) 1.2–3.7, p = 0.0086). This association was successfully replicated in the Finnish Health 2000 study cohort (allelic OR 1.72, 95% CI 1.2–2.5, p = 0.006). FOS Promoter variants may represent relevant susceptibility markers for knee-OA.

京都大学 / 新制・課程博士 / 博士(人間健康科学) / 甲第24097号 / 人健博第104号 / 新制||人健||7(附属図書館) / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 黒木 裕士, 教授 青山 朋樹, 教授 松田 秀一 / 学位規則第4条第1項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM

<p>The purpose of this thesis was to improve the understanding of pain measurement and management in people with knee OA through: 1) Developing a theoretical model that may help in pain management and measurement; 2) Exploring the knee OA individuals’ views about three pain measures and 3) To determine if low frequency (≤100 Hz) pulsed subsensory threshold electrical stimulation produced either through pulsed electromagnetic field (PEMF) or pulsed electrical stimulation (PES) versus sham PEMF/PES intervention is effective in improving pain and physical function in the knee OA population.</p> <p>After pain theories literature review, a theoretical model was developed to address the gap between pain theories and clinical pain measurement and management. The patient’s views about three pain measures were not explored before 96 participants were recruited and completed the Verbal Numerical Rating Scale (VNRS), Intermittent and Constant Osteoarthritis pain Questionnaire (ICOAP) and the Short Form-McGill Pain Quetionnaire-2 (SF-MPQ-2). Participants were asked how well each pain measure describes their pain on a 10 cm Visual Analogue Scale (0 = does not describe your pain at all, and 10 = describes your pain completely. The time taken to complete and score the pain measure as well as the number of errors and questions while filling the pain measures were recorded. Systematic electronic searches were performed. Duplicate title, abstract and full text screening, risk of bias assessment, data extraction and grading the quality of evidence were performed. Data analysis was performed using Revman 5 software.</p> <p>Our sample of individuals with knee OA showed that VNRS, SF-MPQ-2 and ICOAP describe knee OA pain experience with no preference of one over the others. The systematic review conclusion was that PEMF/PES may be beneficial to improve physical function but not pain in people with knee OA with low and very low quality of evidence respectively</p> / Master of Health Sciences (MSc)

INTRODUCTION: Altered walking patterns in individuals with knee osteoarthritis (OA) are a key driver of disease; however, mechanisms underlying this relationship are not clear. Central sensitization is now recognized as an important contributor to pain experience in people with knee OA. In the presence of chronic pain and central sensitization, there are alterations in activity and connectivity across multiple brain regions (e.g., prefrontal cortex, primary motor cortex) that could influence dynamic control of gait. However, the association of central sensitization with gait patterns in knee OA has not been studied. Our objective was to investigate whether central sensitization in individuals with knee OA is associated with dynamic control of gait as assessed using wearable sensor-derived measures of gait complexity and dynamic stability. We hypothesized that a greater degree of sensitization would be associated with lower gait complexity and stability. METHODS: We used data from the 12th-year visit of the Multicenter Osteoarthritis Study, a longitudinal cohort study of individuals with and without knee OA. This was the first visit at which the relevant gait parameters were collected using wearable sensors. Individuals from this visit with valid data available for all measures contained in this analysis were included. Mechanical temporal summation (TS), an augmented response to repetitive mechanical stimulation, is a reliable and valid measure of central sensitization. To assess TS, participants’ pain ratings were assessed after a single wrist stimulus was applied with successively weighted probes until a pain rating of at least 4/10 was achieved (the highest weighted probe was used if that pain rating was not obtained), then was assessed again after 10 repeated stimuli at a rate of 1 Hz was applied with the same probe. A post-stimulation pain rating larger than the initial pain rating reflected facilitated TS. For gait analyses, participants completed 2 trials of a 20m walking test at their usual walking pace while wearing inertial sensors on their lower back and both feet. The lower back sensor was used to calculate sample entropy and Lyapunov exponent, both of which may provide a window into how dynamic control of gait is altered in disease. Sample entropy measures the inter-stride predictability or regularity of gait kinematics. Lower sample entropy represents a more regular or predictable (i.e., less complex) gait pattern and may reflect a reduced ability of the neuromotor system to adapt to ongoing changes experienced in daily walking. LE measures the inter-stride stability of gait kinematics. Large LE values represent more gait instability and may reflect a reduced ability of the motor system to recover from small perturbations. We averaged the gait outcomes across the two trials. Exposure variables were standardized. We determined the association between TS and gait parameters using linear regression while adjusting for age, sex, race, body mass index (BMI), depressive symptoms, education, and presence of radiographic knee OA. Analyses were not adjusted for pain or gait speed because we hypothesized that these impairments were on the causal pathway between our exposure and outcomes. RESULTS: Data from 2,179 participants (age = 62.4 ± 10.0 years, BMI = 29.1 ± 5.5 kg/m2, 56.3% female) were included in the analysis. One standard deviation (SD) increase in TS was associated with a -0.024 [95% Confidence intervals -0.038, -0.010] change in sample entropy (i.e., more regular gait) but not with a change in LE (-0.002 [95% Confidence intervals -0.008, 0.004]). CONCLUSION: Individuals with knee OA and central sensitization display a less complex or more predictable gait pattern, evidenced by lower sample entropy, likely reflecting a deterioration in dynamic control of gait. However, central sensitization was not associated with an individual’s ability to respond to natural fluctuations that occur in walking, as evidenced by a lack of association with LE. We propose a plausible mechanism in which central sensitization may cause a reduction in gait complexity via continuous nociceptor release of glutamate, NMDAR activation, and changes in motoneuron excitability and inhibition at multiple sites along the motor pathway. Although causality cannot be determined from this cross-sectional study, these findings provide support for an association between central sensitization and specific aspects of the walking pattern in people with knee OA. Interventions to mitigate central sensitization may be useful to improve gait quality in people with knee OA.

Medial osteoarthritis (OA) and lateral OA have distinct characteristic cartilage lesion locations and knee flexion angles associated with lesion development. These types of OA are suggested to be caused by loading when the knee is in extension and mid-range flexion, respectively. This project used subject-specific finite element (FE) models to investigate contact conditions within the extended and flexed knee. A method of creating subject-specific FE models by combining geometry (derived from magnetic resonance imaging scans) and load cases (calculated from motion analysis data) collected from the same subject was developed. This model creation method was validated by comparing experimentally-measured pressure data to contact data calculated by FE models. Models of normal knees in three subjects were created first. Models with larger subject-specific loads had larger displacements and higher stresses and contact pressures. Contact occurred over most of the articulating cartilage surfaces, both in areas of typical cartilage lesions and outside areas of typical cartilage lesions. Parameters in the normal models were then altered to reflect three mechanical changes hypothesized to lead to OA: increased loading, globally decreased cartilage stiffness, and locally decreased cartilage stiffness. Increased loading led to increased displacements, stresses, and contact pressures. Contact shifted anteriorly in the extended knee models to locations of typical medial OA cartilage lesions; contact remained stationary with elevated stress magnitudes in the flexed knee models. Globally decreasing cartilage stiffness had limited effects on contact results. Locally decreased cartilage stiffness led to locally increased displacement and strain and locally decreased stress and contact pressure. Contact again shifted anteriorly in the extended knee models. Potential mechanisms of OA initiation were then proposed. Increased weight or locally decreased cartilage stiffness increased strains within the cartilage. High strains can damage the cartilage matrix fibres, further decreasing cartilage stiffness and eventually leading to cartilage lesions and OA.

Thesis (MScPhysio)--Stellenbosch University, 2012. / Background: Evidence for the effectiveness of physiotherapeutic interventions in the management of knee osteoarthritis (OA) is synthesised in the current clinical guidelines (CGs), providing clinicians with readily accessible and interpretable practice guidelines. However, CGs are often not specific to the local context of the target users, therefore hindering successful implementation of evidence into clinical practice. Formulating succinct and composite recommendations by synthesising the current CGs reporting on the evidence-based (EB) management of knee OA may assure contextual relevance and facilitate implementation of evidence into clinical practice. In addition, multifaceted interventions, such as evidence-based practice (EBP) workshops, are also postulated to promote the implementation of guideline recommendations, thereby enhancing clinical outcomes. Objectives: The primary objectives of this study were to: 1) describe the range of EB physiotherapeutic interventions in the management of knee OA as documented in the current CGs; and 2) develop composite clinical recommendations for a specific group of users working in Jerusalem. A secondary study objective was to ascertain the effect of translating the knowledge through a specifically-designed EBP workshop on the uptake of knowledge and implementation of EBP into clinical practice by physiotherapists working in Jerusalem. The EBP workshop was aimed at educating physiotherapists about the EB physiotherapeutic techniques for knee OA management. Study design: Two studies were conducted. A systematic review (SR) into EB clinical guidelines was conducted to describe and synthesise the available evidence and formulate composite recommendations for knee OA. The results of the SR were used to design an EBP workshop aimed at educating physiotherapists about EB physiotherapeutic techniques for treating knee OA patients. A pre-post quasi-experimental design was then conducted to assess the effect of this EBP workshop on the uptake and implementation of EBP into clinical practice amongst public sector physiotherapists working in Jerusalem. Methodology for quasi experimental study: Physiotherapists who regularly treat knee OA patients were recruited from a list of members registered with the Palestinian Physiotherapy Association Jerusalem. A three-month retrospective audit (initial audit) of knee OA patients’ physiotherapy records kept by the participating physiotherapists was conducted to establish current management patterns. EB strategies for knee OA was presented to the participating physiotherapists during a one-day workshop. A second audit of physiotherapy records was conducted three months after the EBP workshop to establish changes in the selection of physiotherapeutic management techniques for knee OA. Results: The initial audit revealed that the participating physiotherapists utilized one high EB modality namely, exercises, as a core management strategy in knee OA, but did not frequently implement other high EB modalities such as self-management and weight-loss programs. Following the EBP workshop, a statistically significant increase (p=0.008) in the implementation of weight-loss and self-management strategies in the management of knee OA was noted. Conversely, a statistically significant decrease was noticed in using patellar taping (low EB modality) in the management of knee OA (p=0.04). No significant changes were noticed in the utilization of other physiotherapy modalities supported by weak or modest EB recommendations. Conclusion: The study concluded that physiotherapists inherently prescribed exercise as a core management strategy for knee OA. Modalities supported by modest levels of evidence were used as adjunct treatments. The EBP workshop facilitated the increased application of high EB modalities such as weight-loss and self-management programs. The results of this study illustrate that an EBP workshop may be effective in promoting the implementation of EB physiotherapeutic modalities in the management of knee OA. However, larger studies with longer follow-up periods are required. / No Afrikaans abstract available

La rupture du ligament croisé antérieur du genou est très fréquente, notamment dans les activités qui impliquent des contraintes en rotation. Une dégénérescence du cartilage articulaire du genou peut par la suite engendrer une arthrose. Le but de cette étude était d’une part dans les pathologies traumatiques et d’autre part dans les pathologies dégénératives, atteignant cette articulation, d’analyser les facteurs prédictifs du contrôle postural et de la récupération fonctionnelle. Les effets d’une rééducation innovante combinant une rééducation conventionnelle réduite avec une rééducation en milieu aquatique ont été comparés à ceux d’une rééducation conventionnelle définie par la Haute Autorité de Santé, sur la cinétique de récupération des compétences proprioceptives et sur l’amélioration fonctionnelle. Le contrôle postural par posturographie et la motricité au moyen de tests cliniques ont été quantifiés chez 67 patients ayant présenté une rupture du ligament croisé antérieur, avant intervention et jusqu’à six mois après intervention chirurgicale. Les effets des paramètres météorologiques sur le contrôle postural et la douleur dans la gonarthrose ont été évalués chez 113 patients, par posturographie et échelle de douleur. Pour une même qualité globale du contrôle postural six mois après ligamentoplastie du genou, les patients ayant suivi le protocole de rééducation innovant utilisaient davantage la somesthésie que ceux ayant suivi une rééducation conventionnelle, qui devaient recourir plus à un mécanisme de compensation. La proprioception était améliorée deux mois après l’intervention chirurgicale par rapport à l’évaluation pré-opératoire chez les patients ayant suivi le protocole innovant. La force musculaire était plus importante chez les patients ayant suivi le protocole de rééducation innovant un mois, deux mois et six mois après intervention. Un mois après l’intervention, la distance de marche parcourue était plus importante chez les patients ayant suivi la rééducation innovante que chez les patients ayant suivi la rééducation conventionnelle. Chez les patients présentant une gonarthrose, une dégradation du contrôle postural était observée lorsque la pression atmosphérique et l’humidité maximale diminuaient au cours de la matinée et lorsque la pression atmosphérique diminuait au cours de la journée. L’augmentation de la douleur était corrélée avec l’augmentation de la température sur la matinée et avec l’augmentation de la température et de l’humidité sur la journée. L’environnement dans lequel évolue le sujet (ex : milieu aquatique, ambiance climatique) a donc une influence sur la performance du contrôle postural. Une meilleure prise en charge en rééducation post-ligamentoplastie du genou permettrait de limiter la nécessité de compensation sur le membre contralatéral par une meilleure utilisation de la somesthésie et ainsi prévenir la survenue de l’arthrose et d’une rupture ligamentaire contralatérale. Ceci permettrait de limiter les coûts socio-professionnels / The knee can suffer damage from either traumatic or degenerative pathology. Anterior cruciate ligament (ACL) injuries frequently occur, especially in activities that including rotational stresses. Degeneration of the articular cartilage of the knee can subsequently result in osteoarthritis. The aim of this study was to analyze the predictive factors of postural control and recovery in traumatic injuries and also in degenerative pathologies of the knee. The effects of an innovative rehabilitation protocol combining reduced conventional rehabilitation with aquatic rehabilitation were compared with conventional rehabilitation defined by the National French Health Authority on the kinetics of recovery of proprioceptive skills and functional improvement. Postural control and motor control using clinical tests were quantified in 67 patients with ACL surgery before and up to six months after surgery. The effects of meteorological parameters on postural control and pain in knee osteoarthritis were evaluated in 113 patients, using posturography and also a pain scale. Six months after knee ligament surgery, both groups attained the same quality of postural control. However, patients who followed the innovative protocol made more used of proprioceptive inputs compared to the group who underwent conventional rehabilitation who made more use of a compensation mechanism. In patients following the innovative protocol proprioception was improved two months after surgery compared to before surgery. Muscle strength was higher in patients who followed the innovative rehabilitation protocol at one, two and six months after surgery. One month after surgery, the walking distance traveled was higher in patients who underwent innovative rehabilitation than in patients who had undergone conventional rehabilitation. In patients with knee osteoarthritis, degradation of postural control was observed when atmospheric pressure and maximum humidity decreased during the morning and when atmospheric pressure decreased during the entire day. Increased pain was correlated with increased temperature in the morning and with increased temperature and humidity during the entire day. The environment in which evolves the subject (aquatic, climatic) thus has an influence on postural control performance. A better management in post-ligamentoplasty rehabilitation of the knee would reduce the need for compensation using the contralateral limb, by better use of somesthesia. This could prevent the occurrence of osteoarthritis and a contralateral ACL injury, which would also reduce costs to the society and health care

Contexte et objectif – Les patients âgés gonarthrosiques présentent une dégradation du contrôle postural. Les méthodes non pharmacologiques sont aujourdhui recommandées comme option de première intention dans la gestion de l’arthrose. L’hydrothérapie fait partie des moyens de rééducation à disposition des patients âgés atteints d’arthrose du genou pour ses effets antalgiques et musculaires. Cependant, peu d’études sont actuellement disponibles concernant l’effet de l’hydrothérapie sur le contrôle postural, associée ou non à des programmes de rééducation individuels ciblés. Par ailleurs, le contrôle postural est susceptible de variations diurnes. Cette étude a eu pour objet de décrire le contrôle postural des personnes gonarthrosiques à quatre périodes de la journée, puis de comparer l’amélioration du contrôle postural au cours de deux programmes de rééducation différents recourant à l’hydrothérapie. Matériel et méthodes - Deux-cent-quatre-vingt quatre patients souffrant d’arthrose du genou ont été inclus dans cette étude. Le bilan posturographique a été réalisé une semaine avant la cure thermale en condition simple (yeux ouverts, support stable) et en conditions sensorielles contradictoires (vision faussée ou indisponible, proprioception perturbée). Pour évaluer les variations diurnes de la stabilité posturale, les patients ont été randomisés à quatre périodes d’essai dans la journée définies comme suit : 8h-10h, 10h-12h, 13h-15h, 15h-17h. L’influence du sexe, de l’âge, de la taille, du poids et de l’indice de masse corporelle sur la stabilité posturale a été évaluée. La gonalgie a également été évaluée à quatre périodes d’essai. Par la suite, les patients ont été randomisés en deux groupes de rééducation différents pour recevoir des traitements aquatiques : groupe cure classique (hydrothérapie efficace prouvée, c’est-à-dire groupe témoin) et groupe cure active (hydrothérapie combinant des programmes de réhabilitation individuels ciblés). Les bilans de posturographie statique ont été réalisés respectivement à 21 jours, 42 jours et 90 jours après le début de l’hydrothérapie. Résultats –Les tests posturographiques ont été réalisés chez 241 patients (âge moyen : 64,8 + 8,7 ans ; 82 hommes). Le contrôle de l’équilibre était plus efficace l’après-midi que le matin à la fois dans les conditions simple (p = 0,012) et sensorielle contradictoire (p = 0,047), en particulier en début d’après-midi lorsque la vision et la proprioception étaient disponibles (p = 0,026) ou perturbées (p = 0,019). La gonalgie a été plus prononcée le matin que l’après-midi (p < 0,001). La variation diurne du contrôle postural était plus marquée chez les patients plus âgés, de poids plus élevé, de sexe masculin, dans les conditions d’essais différentes (p < 0,05). Les deux cures d’hydrothérapie ont eu des effets curatifs considérables sur la restauration du contrôle de l’équilibre. Une meilleure précision des oscillations posturales a été constatée dans le groupe cure active par rapport au groupe cure classique, 42 jours après le début de l’hydrothérapie (p = 0,020), en particulier lorsque la proprioception a été perturbée avec (p = 0,028) ou sans (p = 0,025) vision disponible. Dans les deux groupes a été observée une stabilité posturale comparable dans un délai de trois mois. Conclusions - Cette étude a montré une meilleure stabilité posturale chez les patients atteints d’arthrose du genou, en début d’après-midi par rapport à la fin de matinée dans les situations sensorielles simples ou contradictoires. Il a été constaté que ces variations étaient également liées à l’âge, au sexe, au poids et pourraient être expliquées par la douleur articulaire fluctuante dans la journée. Considérée comme un traitement non pharmacologique applicable et recommandé, l’hydrothérapie est bénéfique à l’amélioration de la stabilité posturale chez les patients âgés atteints d’arthrose du genou, en particulier combinant un programme de réhabilitation individuel ciblé. [...] / Background and Objective – Increasing evidence supports balance control impairment in elderly patients with knee osteoarthritis (OA). Current guidelines recommend non-pharmacologic methods as first-line options in the management of OA. Hydrotherapy is a beneficial training medium for rehabilitation in elderly knee OA patients. However, few indications at present are available concerning the effect of hydrotherapy combining with targeted individual rehabilitation programs to improve balance control. Meanwhile, there is limited data on diurnal variation of balance control in these patients. This study aimed to investigate postural stability in elderly patients with symptomatic knee OA during different periods in a daytime before the spa therapy, then to study the results obtained before and after hydrotherapy to compare the improvement of balance control in these patients in two different water-based rehabilitation programs. Materials and Methods – Two-hundred and eighty-four knee OA patients were enrolled in this study. Static posturography using a vertical force platform was performed one week before spa therapy in simple (eyes open, firm support) and conflicting sensory (vision altered or unavailable, proprioception altered) conditions. To assess diurnal postural variations, patients were randomized to four testing sessions in a daytime defined as follows: 8-10am, 10-12am, 1pm-3pm, 3pm-5pm. Influence of sex, age, height, weight, and body mass index on postural stability was evaluated. Knee pain was also assessed in four testing sessions. Patients were then randomized to two different rehabilitated groups to receive spa therapies. Classic treatment group as a control received the efficacy proven spa water therapy, and active treatment group received spa water therapy combining with targeted individual rehabilitation programs. Static posturographies were carried out respectively in 21 days, 42 days and 90 days after the beginning of hydrotherapy. Results – Posturographic tests were completed for 241 patients (mean age: 64.8 + 8.7 years; 82 males). Balance control was more efficient in the afternoon than in the morning both in simple (p = 0.012) and conflicting sensory conditions (p = 0.047), especially in early afternoon when vision and proprioception were available (p = 0.026) or disturbed (p = 0.019). Patients’ knee pain was more pronounced in the morning than in the afternoon (p < 0.001). Diurnal variation of balance control was more noticeable in older, heavier, and male patients under different testing conditions (p < 0.05). Both the water-based therapies had considerable curative effect on balance control restoration. Better postural sway precision were found in active group than classic group 42 days after the beginning of hydrotherapy (p = .020), especially when proprioception was interfered with (p = .028) or without (p = .025) an available vision. Both of the groups have been observed a comparable postural stability in a three-month term. Conclusions – This study showed that better postural stability was observed in patients with knee OA in early afternoon than in late morning in simple and conflicting sensory situations. These variations appeared also to be related to age, sex, and weight and could be explained by fluctuant joint pain in a daytime. As feasible and recommended non-pharmacologic treatment, hydrotherapy is beneficial to the improvement of postural stability in elderly patients with knee OA, especially combining with targeted individual rehabilitation programs. These findings are important for future studies aiming at enhancing postural stability in knee OA patients and should be taken into account in the management of knee OA to generate applicative approaches to prevent the occurrence of adverse events in patient’s daily life.

L’arthrose est la maladie articulaire la plus fréquente pouvant être responsable d’une perte d’autonomie et d’un handicap fonctionnel majeur. Du fait du vieillissement de la population et de la prévalence de l’obésité, le nombre de personnes ayant une arthrose des membres inférieurs va augmenter dans les années à venir et entrainer une explosion des dépenses de santé. La cohorte « Knee and Hip OsteoArthritis Long-term Assessment » (KHOALA) est une cohorte française multicentrique représentative de patients atteints d’arthrose symptomatique de hanche et/ou de genou.Les objectifs de ce projet étaient d’établir une revue de la littérature sur les conséquences économiques de l'arthrose de hanche et/ou du genou. Puis à partir de la cohorte KHOALA, nous avons décrit la consommation de soins ; identifié les facteurs associés aux trajectoires d'utilisation des ressources de santé et estimé les coûts annuels totaux. Enfin nous avons réalisé une analyse systématique de la littérature sur les analyses coût-efficacité des anti-arthrosiques d’action lente et de l’acide hyaluronique intra articulaire dans l’arthrose de genoux.La revue systématique a objectivé une hétérogénéité des couts totaux par patient (de 0,7 à 12 k€/an). Les données de KHOALA ont démontré que la majorité des patients consultait son médecin généraliste et une minorité de patients consultait un spécialiste. Le seul facteur clinique indépendant prédictif des consultations des professionnels de la santé était l'état de santé mentale. Le coût total annuel moyen par patient sur la période d'étude de 5 ans était de 2180 ± 5 305 €. En France, les coûts médians pourraient atteindre 2 milliards € / an (IQR 0,7–4,3). / Osteoarthritis is the most common joint disease that can be responsible for a loss of autonomy and a major functional disability. With the aging of the population and the prevalence of obesity, the number of people with lower limb osteoarthritis will increase in the coming years and lead to an explosion of health spending. The "Knee and Hip OsteoArthritis Long-term Assessment" cohort (KHOALA) is a representative French multicenter cohort of patients with symptomatic hip and / or knee osteoarthritis.The aims of this thesis were to provide an overview of the economic consequences of hip and knee osteoarthritis worldwide. Then from the KHOALA cohort, we described health care resources use in the KHOALA cohort, we identified factors associated with trajectories of healthcare use and we estimated the annual total costs. Finally, we conducted a systematic review of the literature on the cost effectiveness of intra-articular hyaluronic acid and disease-modifying osteoarthritis drugs used in the treatment of knee OA.The systematic review showed a heterogeneity of the total costs per patient (from 0.7 to 12 k € / year). KHOALA data showed that primary care physicians have a central role in osteoarthritis care, mental health state was the only independent predictive factor of healthcare professional consultations. The mean annual total cost per patient over 5 years was 2180 ± 5,305 €. In France, median annual total costs would be approximately 2 billion €/year (IQR 0.7-4.3).