Journal of American Science 2013;9(5) http://www.jofamericanscience.org

The Relation between Environmental Factors and Health Related Mobility Disability of Elderly Women with Osteoarthritis in Southern

Nadia Abdalla Mohamed

Obstetrics and Gynecology Health Nursing, Faculty of Nursing, South Valley University [email protected]

Abstract: Mobility disability in women with Osteoarthritis is due to the inactivity associated with the disease and to the effects of aging. The surrounding environment may play a key role in shaping patterns of independence and dependence among older women with mobility disability.This study was conducted to identify the prevalence of community mobility barriers and transportation facilitators and examine whether barriers and facilitators were associated with mobility disability among elderly women with Osteoarthritis.A cross-sectional analytic design was used in carrying the study whichconducting targeted women attending the orthopedic outpatient clinic at , Luxor and Aswan General Hospital. Data collection started in October 2009until the end of January 2011 from a convenient sample of 600 elderly women aged 60 years and above, diagnosed with osteoarthritis for at least one year. Three tools were used: tool I is a structured interview sheet which was developed by the researcher including sociodemographic data. Tool II isthe Late-Life Function and Disability Instrument which composed of two domains of disability which were daily activity limitation and daily activity frequency. Tool III isa structured interview sheet to assess the environmental factors.The results showed a weak relationship between the age of the osteoarthritic women and the number of affected joints. There is a positive relationship betweenthe severity of disability and numbers of affected joints, the presence of uneven sidewalks and lack of near public transportation in cities more than rural.So it is recommended to modify the environment at the street level by providing safe and straight sidewalks and providing transportation suitable for osteoarthritic women with suitable seats for elderly. [Nadia Abdalla Mohamed. The Relation between Environmental Factors and Health Related Mobility Disability of Elderly Women with Osteoarthritis in Southern Egypt. J Am Sci 2013; 9(5):408-416]. (ISSN: 1545-1003). http://www.jofamericanscience.org. 53

Key words: Osteoarthritis, Mobility disability, Environment.Disability and elderly women

Introduction metabolic and biochemical factors is proposed Osteoarthritis (OA), are the most common and (Klippel et al., 2010). Age is the most consistently most frequently disabling joint disorders. (Smeltzer et identified demographic risk factor for all articular al., 2008) characterized by altered joint anatomy, sites. However, increasing age does not appear to be especially the loss of articular cartilage. Pathologically an absolute risk factor in the development of OA, for OA may be defined as a condition of synovial joints not every elderly woman develops OA (Lewis et al., characterized by focal loss of articular cartilage and 2010). simultaneous proliferation of new bone (osteophytes) The process by which aging is theorized to with the remodeling of joint contour. (Multani et al., increase risk of OA is depicted. Some of the 2007). It is a localized disorder with no systemic mechanisms and mediators demonstrated in cellular effects. (Schoen, 2000) and system aging are relevant to cartilage and Osteoarthritis is the most prevalent and disabling periarticular structures. These changes may predispose of the chronic conditions affecting elderly the elderly individual to altered biomechanics that femalesworldwide. The prevalence of osteoarthritis increase risk of joint injury to which repair is among women increases dramatically after the age of attempted but eventually fails (Aigner et al., 2007 50 years. Women have twice the risk than men of and Malemud et al., 2003). developing bilateral knee osteoarthritis, and 2.6 times Any joint may be affected, but the relatively the risk of men in developing hand osteoarthritis. lightly stressed joints of the upper limb are, in general, (Felson and zhang, 1998). A withdrawal from less prone to osteoarthritis than the highly stressed estrogen at menopause may be a trigger. (Lewis et joints of the lower limb. Knee OA is more prevalent al., 2010 and Haq & Davatch , 2011). than the hip OA, but taken together they affect 10 to OA is listed eighth as a worldwide cause of 25 % of those aged over 65 years in India (Multaniet disability especially among the elderly women. al., 2007 and Hamblen & Hamish, 2010). (Lewis et al., 2010). The precise mechanism of Major areas affected are the weight- bearing cartilage degradation in osteoarthritis is still unclear, joints (knees, hips, facet joint of the lumbar spine), but a complex interplay of genetic, environmental, facet joint of the cervical spine, distal interphalangeal

408 Journal of American Science 2013;9(5) http://www.jofamericanscience.org joints (DIP), proximal interphalangeal joints (PIP), elderly women. It includes community environment, and first metatarsophalangeal (MTP) joint. Among home environment, communication devices, individual age 70 and elderly who were enrolled in the transportation factors, basic mobility and assistive Framingham study (2003), 13 % of men and 26 % of devices. (Whiteneck and Dijkers, 2009). women reported symptoms of hand osteoarthritis. Community environment means the Osteoarthritis rarely is found on the wrists, elbows, characteristics of the elderly women community shoulder, ankles, or feet except after trauma. Joint environment at the street level (uneven sidewalks). As involvement is unilateral in more than half of all cases a result of declining health and functional status, (Linton & Lach, 2007 and Landefeld et al., 2004) financial strain and social isolation, the elderly women Joint effects differ depending on the site (Cotter & are vulnerable to conditions in the built environment. Strumpf, 2002) Uneven or discontinuous sidewalks are just some of WHO (2004) estimated that the Prevalence of the built environment characteristics that can create OA in the World was 151.4 million, The Americas barriers for outdoor mobility, which can have spillover 22.3 million, Africa 10.1 million, Eastern effects on elderly women' ability to function Mediterranean 6.0 million, Europe 40.2 million, independently in the community. (Clarke et al., 2009 South- East Asia 27.4 million, Western Pacific 45.0 and Hand 2011). million(WHO, 2011). According to “CDC Department of Health, As the incidence and prevalence of osteoarthritis Accessibility and the Environment”; poorly designed rise with increasing age, extended life expectancy will communities can make it difficult for elderly women result in a greater number of people with the with mobility impairments or other disabling condition. In the United Kingdom (UK) 20% to 30% conditions to move about in their environment. (CDC, of elders over 60 years have symptomatic Department of Environmental Health. Accessibility osteoarthritis and up to two million elderly people and the environment. 2012). visit their general practitioner annually because of the Availability of public transportation is a critical disease (Heikkinen et al.,2010). In the United States link in the ability of the elderly women to remain of America (USA) almost 50% of elders in their 70s independent and functional. The lack of accessible and 80s has OA (Keysor et al.,(2005).In the Middle transportation may contribute to other problems such East, More than one million people suffer from OA in as social withdrawal, poor nutrition, or neglect of Iraq, Yemen, Saudi Arabia, and Syria (Halter et health care. A crisis in mobility exists for many al.,2009). In Egypt, more than five million people elderly women because of the lack of an automobile, have OA(Hassan,2011). an inability to drive, limited access to public Approximately 85% of individuals over the age transportation, health factors, geographical location, or of 75 years of age experience some symptoms of economic consideration. Rural residence may osteoarthritis. 40% of individuals with the disorder experience more difficulty than urban residents. experience significant difficulties with daily activities (Howie et al.,2012) to the point of interfering with work-related or social The study area includes; Aswan, Luxor, and roles (Stevermer,2005).Regarding prevalence rate of located in southern Egypt). Egypt is osteoarthritis in different countries. In Sweden it was geographically divided into Upper (south) and Lower reported to be 61 % (1992), in the Netherlands 45.7 % (north) Egypt, according to the flow of the River Nile, (1992), in Europe and America 30 % (2003), in which drains from South and heading northward. So, Australia 20 % (1998), in in UK 12 % (2003), and in the Southern part of Egypt is called Upper Egypt. Saudi Arabia it affects 11.3 % of elderly female Egypt is located in the northeastern corner of the (1990) (March & Bagga, 2004;Armour & Cairns, African continent and a part of the Middle 2002;Bagge et al.,1992, Tallis & Fillit, 2003 East,bounded by the Mediterranean Sea, Red Sea, andAhlbeg et al.,1990). Libya, and Sudan from north, east, west and south, According to the WHO, disability is an umbrella respectively(Fig, 1).It covers approximately term for impairment, activity limitation, participation 1,001,450sq. Km.), Egypt, which is the formal used restrictions, and environmental factors. A woman’s name but Misr is the name used by the people functioning or disability is viewed as a dynamic of the country. It is derived from the Greek interaction between health conditions (i.e., diseases, ‘Aegyptos’, which probably comes from ancient disorders, injuries, trauma) and contextual factors (i.e., Egyptian words referring to the land (Wikipedia). personal and environmental factors). Disability is not According to Walter (1996) the Egyptian population is an “all or nothing” concept. There is a wide range of quite homogeneous. In addition, Islam is practiced by functional limitations (Smeltzer et al., ( 2008). the majority of the Egyptian population (90%) and it The physical environment can be critical to rules their personal, economic, political, and legal effective functioning, particularly for the disabled lives. In Egypt, men and women have equal legal

409 Journal of American Science 2013;9(5) http://www.jofamericanscience.org rights. However equality is not determined only by use of health services. (Aijanseppa et al.,(2005) and law, culture plays a role. Walter (1996). Boonen &Maksymowych,2010). One of the worst things about OA is its negative Question research effect on quality of life. This may lead to loss of self- What are the environmental factors that are esteem, depression and deterioration of personal associated with health related mobility disability of relationships and professional careers.Also, reducing elderly women with osteoarthritis? the functional capacity of a women and results in What is the relation between environmental disability (Multani et al., 2007).Incapability in factors and health related mobility disability of elderly performing everyday activities independently and women with osteoarthritis? resultant loss of personal autonomy are undesirable The objectives of this study were to (a) Identify consequences of functional impairment at the the prevalence of community mobility barriers and individual level. At the population level impaired transportation facilitators and (b) examine whether functioning is associated with increased mortality and barriers and facilitators were associated with disability among elderly women with mobility disability.

Figure 1. Landsat ETM+ mosaic of Egypt showing the study area that marked by the blue polygon in south Egypt including; Qena, Aswan and Luxor governors.

2. Materials and method legion with rarely rainfall except sun shower from Research design: time to time. Mainly composed of rock, hills and The study followed the cross sectional design. elevations. Settings: Sample Size: The study was carried out at the orthopedic The study included 600 elderly women (Qena , Outpatient Clinics of Qena, Luxorand Aswan General Luxor and Aswan ) Hospital. Study sample: Study area located in southern Egypt included Inclusion criteria included: Qena, Luxor and Aswan along the Nile bank pounded Aconvenient sample of 600 elderly women aged from East by Red sea and western desert, Libya, from 60 years and above, diagnosed with osteoarthritis for North and the Mediterranean Sea and from South, at least one year and reported of “any difficulty” on at Nasser Lake. The area is very hot in summer least two of the following three items on the Western (temperature = 40 0 c) and very cold in the winter Ontario and McMaster Osteoarthritis Index (temperature = 24 0 c). Generally the area is arid (WOMAC) (Keysor et al 2010).

410 Journal of American Science 2013;9(5) http://www.jofamericanscience.org

(1) Going upstairs. the morning hours, 9:00 A.M to 1: P.M. Each (2) Rising from sitting. interview took about 10 to 25 minutes. They took (3) Bending or squatting to the floor. about three years. The researcher introduced herself to Exclusion criteria included: the eligible women and briefly explained the nature of Women with diseases causing disability such as the study. (heart disease, diabetes mellitus, and rheumatoid Administrative approval: arthritis). The necessary official permission was obtained Tools of data collection: from the top manager of each general hospital to Three tools were used proceed with the study The tool I: A Pilot study was conducted in60 of the sample, who A structured interview sheet was developed by was excluded from the study, to assess the clarity of the researcher to collect the relevant data which the tools and estimate the time required for filling the include sociodemographic data such as the age of sheet. women, educational level and site of osteoarthritis. Ethical consideration: Tale II: A formal consent was obtained orally from The Late-Life Function and Disability women before being involved in the study. The nature Instrument (LLFDI) was developed by Jette et al., and purpose of the study were explained. The (2004).It's composed of two domains of disability, (a) researchers informed the women that there is no risk daily activity limitation (DAL) and (b) daily activity or cost for participation, and the participation is frequency (DAF).All items on the LLFDI were scored voluntary. Also, the women were assured that the on a 5-point Likert-like scale: None (have no confidentiality of information will be done and difficulty doing the activity), A little (can do it alone anonymity of each subject was maintained. with a bit of difficulty), Some(can do it, but have a Spatial analysis moderate amount of difficulty doing it alone) , Quite a The collected data were statistically analyzed lot (can manage without help, but have quite a lot of using spreadsheet (Excel). The average of the difficulty doing it)and Cannot do (It is so difficult that response was computed by excel sheet. cannot do it unless have help)scored 5, 4, 3, 2 and 1 The variables as disabling frequency, disability respectively. limitation, the presence of public transportation and Tool III: presence of uneven sidewalks were analyzed and A structured interview sheet to assessthe integrated using Geographical Information system environmental factors including Presence of (GIS) software packages. community barriers (uneven sidewalks or other In order to understand the spatial distribution of walking areas) and facilitators (Public transportation the osteoarthritis disability in Qena, Aswan and Luxor that is close to women’s home)) was ascertained by Governorates, the data were processed using the Home and Community Environment survey which Geographic Information Systems (GIS) software was developed by Keysor et al., 2005.Based on the packages e.g., Arc GIS 9.3.1. Different thematic maps relevant literature the researcher found that these two e.g., sites of osteoarthritis "1 (knee), 2 (Hip), 3 items are the most affected and more common. The (lumbar), 4 (cervical)", average of disabling frequency response was scored as 0fordon't know, 1for not at (AVGDF), average of disability limitation (AVGDL), all, 2forsome and 3fora lot. uneven sidewalks (community barriers) (COM), near The tools were face and content validated through the public transportation (TRANS), education (EDU), and opinions of five experts in Obstetrics &Gynecology ages were prepared using interpolated methods e.g., and community health both nursing and medicine. The Inverse Distance Weighting (IDW) method as a panel reviewed the tools for comprehensiveness, function of Arc GIS tools. Each map has been relevance, and clarity. The tools were modified classified into four classes and ranked by a numeric according to the panels' recommendations. As for the scale (1 to 4 where 4 is the highest value and 1 is the reliability, The Late-Life Function and Disability lowest. All maps were integrated in the Arc GIS Instrument' internal consistency and the Home and using the Raster Calculator as a function of the Spatial Community Environment were measured. They Analyst tools (e.g., Eastman et al., 1995; Eastman proved to be of good reliability with Cronbach alpha 1996; Vooged 1983 and Abdelkareem et al., 2012) coefficients 0.85 and 0.78, respectively. as given below: Field work: Site of osteoarthritis potential map1 = Site 1+ The study started at the October2009until the end Site 2+ Site 3+ Site 4 of January 2011.The numbers of osteoarthritic elderly Disability and environmental factors potential women who visit the outpatient clinics increase in the map2 = AVGDF+ AVGDL+ COM+ TRANS winter of each year. Data collection was done during

411 Journal of American Science 2013;9(5) http://www.jofamericanscience.org

Each final map formed by the above equation Site two: the spatial distributionof Hip was divided into five categories ranked by a numeric osteoarthritis is most common in NagaaHammadi, scale (1 to 5 where 5 is the highest value and 1 is the Qus,, Esna, and KomOmbo (Fig. 2b). lowest). Site three: the spatial distribution of Lumbar osteoarthritis is more common in Abu Tesht, Qus,Qift, 3. Results Edfu, Esna and Komombo (Fig. 2c). Results of interpreting the spatial distributions Site four: the spatial distribution cervical and GIS analysis are given below in reference to the osteoarthritis is less distributed in the study area; distribution of osteoarthritis in three governorates in however cities e.g., NagaaHammadi, Qus, Edfu, Egypt. and Kom Ombo record higher density (Fig. 2d). Site one: the spatial distribution of Knee osteoarthritis is most common in Dishna, Nagaa Hammadi, Qus, Luxor, Edfu, and Aswan (Fig. 2a).

Figure 2.Thematic maps. (A, b, c, d) showing sites of osteoarthritis inthe knee, Hip, lumber, and cervical, respectively. (e) Average of disabling frequency (AVGDF); (f) average of disability limitation (AVGDL), (g) uneven sidewalks (COM); (h) near public transportation (TRANS).

Disability frequency distribution (AVGDF1) in the study area showed moderately positive relationships with other osteoarthritis sites. The higher level is most common in NagaaHammadi, Al Wakf, Qena, Qus, Luxor, Esna and Komombo. It decreases in Aswan(Fig. 2e). Disability limitation (AVGD) is less distributed through the study area and most of the investigated sites showing low density but some cities e.g., Dishnaand areas between Esna and Edfu record high density(Fig. 2f). Uneven sidewalks: most of the investigated area showed low uneven sidewalks but Abu tesht, Dishna and Esna record higher values. This revealed the high topography areas with low road quality (Fig. 2g). Transportation: Near public transportation is most common in Dishna, NagaaHammadi, Qus, Luxor and Komombo(Fig. 2h).

412 Journal of American Science 2013;9(5) http://www.jofamericanscience.org

DF, DL, uneven sidewalks and public transportation are most common in NagaaHammadi, Dishna, Qena and Luxor. Elderly people are few and have OA in four joints. Finally disability is more common in NagaaHammadi, Dishna, Qena and Luxor.

Figure 3. Integrated maps. (a) Osteoarthritis density map integrated including knee, Hip, lumber, and cervical sites; (b) Integrated map of average of disability frequency (AVGDF), average of disability limitation (AVGDL), uneven sidewalks (COM), near public transportation (TRANS); (c) Distribution of the education levels in the study area; (d) Distribution of the age in the study area.

There is a weak relationship between the age of Also, there isn't a significant relation between the osteoarthritic women and the number of joints education level, number of affected joints and affected by osteoarthritis. This is observed in Dishna disability. and Luxor while in Aswan and Edfu there is a relation between age and number of affected joints.It was Discussion observed that there is a relation between age and Based on data integration and correlation, disability thereisa weak relationship between the age of the Despite the increase number of young older osteoarthritis women and the number of joints affected women (60-69 years) in north of us, NagaaHammadi by osteoarthritis (Fig 3, map a & d) due to there isn't and Dishna, those women have more affected joints. an apparent difference between categories of age (60 These results reflect that there is a strong relation to 75 years). This is observed in Dishna and Luxor between the numbers of affected joints and disability. while in Aswan and Edfu. There is a relation between In NagaaHammadi, Dishna, Qena, Qus and Luxor.The age and number of affected joints because the study severity of disability increase with the increasing sample from Aswan aged 85 years and also 60 years. presence of uneven sidewalks (COM1) and lack of This means that apparent difference between public transportation (TRANS). categories of age. It was observed that there is a

413 Journal of American Science 2013;9(5) http://www.jofamericanscience.org relation between age and disability (Fig 3, map b & d) due to higher floors, low economic status, overload Conclusion tasks, heavy activities and high parity. Despite the From previous results, it can be concluded that in increase number of young older women (60-69 years) cities such as NagaaHammadi, Dishna, Qena, Qus and in north of us, NagaaHammadi and Dishna, those Luxor.The severity of disability increase with the women have more affected joints(Fig 3, map a & increasing presence of uneven sidewalks and lack of d).These results reflect that there is a strong relation public transportation. between the numbers of affected joints and disability (Fig 3, map a & b). The increasing numbers of Recommendation: affected joints, increasing the severity of disability in Organize with local units of each city to modify cities more than rural in NagaaHammadi, Luxor, environment at the street level by providing safe and Dishna and Qus.This finding is in disagreement with straight sidewalks. the studies done by Clarke et al., (2005)and (2009) in Providing transportation suitable the USAwhich suggest that older women living in forosteoarthritiswomen with suitable seats for elderly urban settings are less likely to be disabled. Also other or other kinds of help to enable olderwomen to studies done by Joshi et al., (2003) and Medhi et al., participate in social activities. (2006) in India reported rural-urban differences in the prevalence of mobility disability. Corresponding author Maintaining mobility independence of older Nadia Abdalla Mohamed women with OA who are at the greatest risk for Obstetrics & Gynecological Health Nursing, Faculty functional decline and disability in the environment is of Nursing, South Valley University an important goal of obstetric nursing. Older women [email protected] who lose independent mobility are less likely to remain in the community. They have higher rates of References morbidity, mortality, self-care disability and 1. Abdelkareem M.; F. El-Baz, M. Askalany, A. experience a poorer quality of life. (Gill et al., 2012) Akawy and E. Ghoneim (2012). Groundwater In NagaaHammadi, Dishna, Qena, Qus and Prospect Map of Egypt’s Qena Valley uses Data Luxor the severity of disability increase with the Fusion. International journal of images and data increasing presence of uneven sidewalks and lack of fusion, 3 : 169-189. near public transportation (Fig 3, map b). 2. Ahlbeg A.; B. Linder and T.A. Binhemd(1990). Concerningpresence of uneven sidewalks, the Osteoarthritis of the hip and knee in Saudi Arabia. previous finding goes harmony with other studies Int Orthop,14: 29- 30. done by Keysor et al.,(2008) and Meyers et 3. Aigner T, Haag1 J, Martin J, Buckwalter J. al.,(2002)which found that people who reported a Osteoarthritis (2007). Aging of Matrix and Cells - greater presence of community mobility barriers were Going for a Remedy. Current Drug Targets, 8: likely to report more mobilitydisability. While other 325-31. studies done by Haak et al., (2008) in USA and 4. Aijanseppa S, Notkola I, Tijhuis M, Staveren W, Oswald et al., (2007) in Germany who used the same Kromhout D, Nissinen A. Physical functioning in environmental assessment scale stated that a number elderly Europeans (2005). 10 year changes in the of environmental barriers was not associated with north and south: the HALE project. J Epidemiol mobility disability among elders. Community Health,59:413–419. In relation to public transportation, the previous 5. Armour D, Cairns C. (2002). Medicines in the finding is in the same direction with the study done by elderly. London: Pharmaceutical press Co., 300-9. Keysor et al (2010) in the USA who found that, 6. Bagge E, Bjelle A, Valkenburg HA, Svanborg people reporting fewer transportation opportunities in (1992). Prevalence of radiographic osteoarthritis in their community perceived more limitation in their two elderly populations. Rheumatol in, 12: 33-8. daily activities. The same findings were reported by 7. Boonen A, Maksymowych W. (2010). most cross-sectional studies done by Talbot et al., Measurement: function and mobility (focusing on (2004) in Canada and Fuzhong et al., (2008) in the the ICF framework). Best Practice & Research USAthat, public transportation was associated with Clinical Rheumatology, 24: 605–624. going outside the home and physical activity in older 8. CDC, Department of Environmental Health. adults. Accessibility and the environment.Available at Also, there isn't an apparent relation between http://www.cdc.gov/healthyplaces/healthtopics/acc education level, number of affected joints and essibility.htm.Retrieved on 3/2/2012. disability(Fig 3, map a & c). Each one of the study 9. Clarke Ph, Ailshire J, Lantz P. (2009). Urban built variables can affect the others. environments and trajectories of mobility

414 Journal of American Science 2013;9(5) http://www.jofamericanscience.org

disability: Findings from a national sample of 23. Heikkinen E, Ebrahim S, FerrucciL,Guralnik J, community- dwelling American adults (1986– Rantanen T, Marianne S. (2004). Disability in Old 2001). Social Science & Medicine,69: 964–70. Age (Final Report). University of Jyväskylä. 10. Clarke Ph, George L. (2005). The Role of the Built Availablehttp://www.jyu.fi/BURDIS/.Retrieved on Environment in the Disablement Process. 25/11/2010. American Journal of Public Health, 95 : 1933–39. 24. Heikkinen E. (2003). What are the main risk 11. Cotter V, Strumpf N. (2002). Advanced practice factors for disability in old age and how can nursing with elderly adults: clinical disability be prevented? (Health Evidence Network guidelines.New York: The McGraw- Hill report). Copenhagen, WHO. Available at companies, 238- 42. http://www.euro.who.int/document/E82970.pdf. 12. Eastman, J.R. (1996). Multi-criteria evaluation and 25. Howie E, Barnes T, McDermott S, Mann J, GIS. In: P.A. Longley, et al., eds. Geographical Clarkson J, Meriwether R. (2012). Availability of information systems. 2nd ed., Vol. 1, New York: physical activity resources in the environment for John Wiley and Sons, 493–502. adults with intellectual disabilities. Disability and 13. Eastman, J.R. (1995). Raster procedure for multi- Health Journal, 5: 41-48. criteria/multi-objective decisions. 26. Joshi K, Kumar R, Avasthi A. (2003). Morbidity Photogrammetric Engineering and Remote profile and its relationship with disability and Sensing,.61, 539–547. psychological distress among elderly people in 14. Felson DT, Zhang Y. (1998). An update on the Northern India. Int J Epidemiol,32 : 978-87. epidemiology of knee and hip osteoarthritis with a 27. Keysor J, Jette A, LaValley M, Lewis C, Torner J, view to prevention. Arthritis Rheu, 41 : 1343-1355 Nevitt M, Felso D. (2010). Community 15. Fuzhong Li, Harmer P, Cardinal B, Bosworth M, Environmental Factors Are Associated With Acock A, Johnson-Shelton D, Moore J. (2008). Disability in Older Adults With Functional Built Environment, Adiposity, and Physical Limitations: The MOST Study. Journal of Activity in Adults Aged 50–75. Am J Prev Med., Gerontology: Medical Sciences,65 : 393– 99. 35: 38–46. 28. Keysor J, Jette A, Haley S. (2005). Development 16. Gill Th, Gahbauer E, Murphy T, Han L, Allore H. of the Home And Community Environment (2012). Risk Factors and Precipitants of Long- Instrument. American journal of Rehabilitation, Term Disability in Community Mobility. Annals 37: 37- 44. of Internal Medicine journal,156: 131- 40. 29. Keysor J. (2008). Home and Community 17. Haak M, Fänge A, Horstmann V, Iwarsson S. Environment (HACE) Survey: Instrument and (2008). Two dimensions of participation in very Scoring Manual. Department of Physical Therapy old age and their relations to home and and Athletic Training, Boston University,. neighborhood environments. American Journal of Available at http://www.bu.edu. Occupational Therapy; 62 : 77-86. 30. Klippel J, Giles W. A. (2010). National Public 18. Halter J, Ouslander J, Tinetti M, Studenski S, High Health Agenda for Osteoarthritis. Center for K, Asthana S. (2009). Hazzard’ Geriatric Medicine Disease control and Prevention & Arthritis and Gerontology. 6thed. New York:The McGraw- Foundation,;1-62.Availableat Hill companies, 1411-19. www.cdc.gov/arthritis/docs/OAagenda.pdf . 19. Hamblen D, Hamish A. (2010). Adams's outline of Retrieved on 12/1/2012. Orthopaedics.14th ed. China: Elsevier company, 31. Landefeld C, Palmer R, Johnson M, Johnston C, 140-43. Lyons W. (2004). Current Geriatric diagnosis 20. Hand C. (2011). Neighbourhood and Social &treatment.New York: The McGraw- Hill Influences on Participation in Everyday Activities companies,; 257-59. Among Elderly Adults with Chronic Health 32. Lewis SH, Heitkemper M, Dirksen SH. Conditions. Published thesis, DSN, Hamilton, (2010).Orthopedic examination, evaluation and Ontario: McMaster University, School of Graduate intervention. 2nd ed. Philadelphia: Mosby Studies, Available athttp://www.proquest.com. company, 1745- 49. 21. Haq S, Davatch F. (2011). Osteoarthritis of the 33. Linton A, Lach H. (2007). Gerontological knees in the COPCORD world. International nursing.3rd ed. Philadelphia: Elsevier company, Journal of Rheumatic Diseases, 14: 122–129. 272-77. 22. Hassan, B. (2011). Comparative clinical study of 34. Malemud CH, Islam N, Haqqi T. (2003). non-pharmacologic interventions for relieving Pathophysiological Mechanisms in Osteoarthritis moderate to severe knee pain in elderly patients. Lead to Novel Therapeutic Strategies. Cells Unpublished thesis, DSN, : University Tissues Organs,174: 34–48. of Alexandria , Faculty of Nursing,.

415 Journal of American Science 2013;9(5) http://www.jofamericanscience.org

35. March L, Bagga H. (2004).Epidemiology of 42. Stevermer C. (2005). Functional movement osteoarthritis in Australia. MJA, 180 : 6-10. assessment for individuals with knee osteoarthritis. 36. Medhi GK, Hazarika NC, Borah PK, Mahanta J. Published thesis, DSN, Iowa: Iowa State (2006). Health problems and disability of elderly University, Faculty of the Graduate,. Available at individuals in two population groups from same http://www.proquest.com. geographical location. J Assoc Physicians India, 43. Talbot L, ViscogliosiCh, Desrosiers J, Vincent C, 54 : 539-44. Rousseau J, Robichaud L. (2004). Identification of 37. Meyers AR, Anderson JJ, Miller DR, Shipp K, rehabilitation needs after a stroke: an exploratory Hoenig H. (2002). Barriers, facilitators and access study. Health Qual Life Outcomes; 2: 53. for wheelchair users: substantive and method- Available at http://www.biomedcentral.com. ologic lessons from a pilot study of environmental 44. Tallis R, Fillit H. (2003). Geriatric medicine and effects. Soc Sci Med.,55:1435–1446. gerontology. 6 th ed. Londone: Churchill 38. Multani N, Ouslander J, Verma S. (2007). Livingstone Co., 896-98. Principles of geriatric physiotherapy. New Delhi: 45. Vooged, H., (1983). Multi-criteria evaluation for Jaypeebrotherscompany, 92-97. Urban and Regional Planning. London: Pion. 39. Oswald F, Wahl HW, Schilling O, Nygren C, 46. Walter, A. (1996). Mass culture and Modernism in Fänge A, Sixsmith A, Sixsmith J, Széman Z, Egypt. Cambridge: University of Cambridge Press. Tomsone S, Iwarsson S. (2007). Relationships 47. Whiteneck G, Dijkers, M. P. (2009). Difficult to between housing and healthy aging in very old measure constructs: conceptual and age. Gerontologist, 47 : 96-107. methodological issues concerning participation 40. Schoen D. (2000). Adult Orthopaedic Nursing. and environmental factors. Archives of Physical Philadelphia: Lippincott Williams & Wilkins Medicine and Rehabilitation; 90: 22 – 35. company, 43-60. 48. WHO. Disease incidences, Prevalence and 41. Smeltzer S, Bare B, Hinkle J, (2008). Cheever. disability. Available at Brunner &Suddarth’s Textbook of Medical- http://www.who.int/healthinfo/global_burden_dise Surgical Nursing.11th ed. Philadelphia: Lippincott ase/GBD_report_2004update_part3.pdf.Retrieved Williams & Wilkins company, 1914-16, 174-85. on 23/12/2011.

3/12/2013

416