Prospective study of physical activity and quality of life in Japanese women undergoing total hip arthroplasty

J Orthop Sci (2013) 18:45–53 DOI 10.1007/s00776-012-0318-5

ORIGINAL ARTICLE

Prospective study of physical activity and quality of life in Japanese women undergoing total hip arthroplasty Kimie Fujita • Kiyoko Makimoto • Riki Tanaka Masaaki Mawatari • Takao Hotokebuchi

•

Received: 8 March 2012 / Accepted: 13 September 2012 / Published online: 25 October 2012 Ó The Japanese Orthopaedic Association 2012

Abstract Background Improvement in quality of life (QoL) in patients who went through total hip arthroplasty (THA) is well studied, while the number of studies on improvement in actual daily activity in THA patients is limited. The purpose of the study was (1) to describe the pre- to postoperative changes in physical activity (PA) levels, (2) compare PA levels with healthy controls, and (3) examine the association between PA levels and QoL in Japanese women undergoing THA. Methods PA was measured by pedometers, and QoL was assessed by the Short-Form 8 and the Oxford Hip Scale questionnaires. Consecutive patients undergoing primary THA at Saga University Hospital, Japan, in 2008 were eligible for the study. QoL and pedometers with accelerometers were mailed to THA patients 1 month pre-THA and 6 and 12 months post-THA. The control group completed a single assessment of questionnaires and pedometers. Results Thirty-eight THA patients completed the study. Preoperatively, the patient group had significantly lower QoL scores than the comparison group. However, these differences disappeared by 12 months post-THA. When improvement of PA function in THA patients was

K. Fujita (&) Department of Nursing, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan e-mail: [email protected] K. Makimoto Department of Nursing, Osaka University, 1-7, Yamadaoka, Suita 565-0871, Japan R. Tanaka
M. Mawatari
T. Hotokebuchi Department of Orthopedic, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan

compared with healthy controls, light PA was already 78 % of the healthy controls at the pre-THA period and improved to 90 % at 12 months. In contrast, moderate PA was 27 % of the controls and rose to 77 % by 12 months, and vigorous PA remained low throughout the study period. PA was correlated with QoL scores. Conclusion The study shows the relative recovery process of PA indicators in THA patients and the contribution of PA to the improvement of QoL.

Introduction Total hip arthroplasty (THA) is a standard treatment for patients with advanced osteoarthritis (OA), and many studies invariably have shown significant improvement in quality of life (QoL) following THA [1–4]. Physical function is associated with improved QoL among older adults [5]. Physical function is also associated with health-related QoL among people with arthritis [6]. In contrast, the recovery process of physical function in THA patients has been limited, and measurement methods to evaluate the physical function vary among studies. Physical functions in THA patients were mostly measured by perceived physical functioning or functional capacity to perform activities in the non-home setting, and physical activity (PA) in patients’ home situations has rarely been examined [7]. Further, the contribution of PA to the improvement in QoL has not been documented. The most important physical function for THA patients is performing actual daily activities, such as activities required at work, housekeeping, and leisure. Our qualitative study found that THA patients became gradually able to resume housekeeping or to return to work as well as fulfill a social role, and they were able to carry out daily activities, getting used to prostheses [8]. PA levels are commonly measured by

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self-administered questionnaire [9–11]. However, selfreported activity levels may not accurately reflect objective measurement of physical activity. Assessment of the reproducibility and relative validity of one physical activity scale (SQASH) showed only modest overall test–retest reliability (r = 0.58) and modest relative validity (r = 0.45) compared with accelerometer activity counts [11]. More objective measurements of PA levels among THA patients have been conducted using pedometers [12–14]. The patients in these studies were assessed at a single time point rather than being followed prospectively, and the recovery of actual daily activity in the home situation in the post-THA period has not been described to date. Additionally, QoL was not measured concurrently. The purpose of this study was (1) to describe prospective changes (preoperative, 6 months, and 12 months after THA) in PA levels, as objectively measured by accelerometers with pedometers (hereafter, pedometers), (2) to examine concurrent changes in QoL in Japanese women undergoing and recovering from THA, (3) to compare these results with those of a healthy control group, and (4) to assess the association between PA and QoL.

Materials and methods Patients All consecutive patients who were scheduled to undergo primary THA for OA in the Department of Orthopedic Surgery at Saga University between October and December (2008) were asked to participate in the study. All the THAs were performed by the last author, and all the THAs were cementless. The study hospital had a well-established critical path, and patients are discharged on average after 14 days of hospitalization. Inclusion criteria were (1) no disabilities in the lower limbs other than the operated hip, (2) women, and (3) able to self-administer the questionnaire in Japanese. Only women were asked to participate as over 80 % of the patients at the study site were women. For a healthy comparison group, convenience sampling was used; graduate students’ parents and their acquaintances were asked to participate in the study. Age-matching was used when recruiting control subjects. Eligibility criteria for the healthy comparison group were those who were able to ambulate without any difficulty. Body mass index (BMI) was not included in the eligibility criteria because the obesity is rare in Japanese patients. Procedure Patients on the THA waiting list were contacted by phone and asked to participate in the study about 4 weeks before

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THA. During the phone call the purpose of the research and research protocols was explained to the participants. Questionnaires and pedometers (Lifecorder EX, Suzuken, Nagoya, Japan) were mailed to the consenting patients at three times: 1 month before THA and 6 and 12 months after THA. Pedometers were used to measure the number of steps per day and PA levels. The demographic characteristics of the patients were collected by self-administered questionnaires and medical records before THA. Weight and height data for the study subjects and healthy controls were obtained from self-administered questionnaires, and weight and height data from medical records for the study subjects were also obtained. To compare PA levels with a healthy comparison group, women matched for age in the Saga Prefecture were asked to participate in the study. The comparison group was asked to fill out the SF-8 once. Ethical considerations The study was approved by the ethics committee of Saga University School of Medicine. Participants were informed that (1) study participation was voluntary, (2) study participation would not affect treatment, (3) they could withdraw from the study at any point, and (4) only aggregated data would be presented. Written informed consent was obtained from the patients, and individual study results were mailed to the participants within 1 week of returning the pedometers. PA level measurements The pedometers measured the intensity of PA. Participants were qustioned by telephone, and a written explanation with color pictures displaying how to wear pedometers were mailed to them. They were requested to wear the device from the time of waking to bedtime on a belt at waist level above the leg for 10 consecutive days. The side of the waist for pedometer placement was not specified as a previous study found no statistical differences in the mean number of steps of the pedometers attached to the both sides in 61 THA patients [15]. Of these 10 days, data from the first 2 days and last 1 day were excluded from analysis, leaving a total of 7 days of data for analysis. Lifelyzer basic software (Suzuken, Nagoya, Japan) was used to analyze pedometer data, tabulating the number of steps and the intensity of PA as expressed by the metabolic equivalent task (METs). The validity and reliability of Lifecorder have been described previously [16, 17]. The PA levels were categorized into light (B3 METs, e.g., walking at a slow pace), moderate (3-6 METs, e.g., climbing stairs), and vigorous (C6 METs, e.g., hiking), and the duration (min per day) of each PA level was tabulated. The patient group

Physical activity and QoL among THA patients

47

was assessed three times (pre-THA and 6 and 12 months post-THA), while the comparison group was assessed once. Health-related QoL As a generic scale, the SF-8 was used to assess QoL. The SF-8 has eight subscales, and the summary scores for physical (PCS) and mental (MCS) scores were tabulated in this study. The total score ranges from 0 to 100, and higher scores indicate better QoL [18]. The Oxford Hip Score (OHS) is a scale used to measures QoL in patients with hip problems [19]. The OHS consists of 12 items addressing physical functions and pain, and its total score ranges from 12 to 48 (the higher the score, the lower the QoL). The previously validated Japanese version of the OHS (OHS-J) was used in this study [20]. Statistical analyses Changes in the PA and QoL outcomes in the patient group across the three assessment times were tested by one-way repeated-measures ANOVA (one group with three times). Non-paired t-tests with Bonferroni correction were used to compare data between the THA group and the comparison group. Effect sizes of the QoL outcomes were calculated to compare our study results with those of previous studies [4]. The degree of relative recovery was examined to compare PA function of THA patients with that of healthy controls by dividing each PA indicator of THA patients by that of controls. Spearman correlation coefficients were used to test the associations between PA level and QoL.

Results Sixty-two patients were eligible and agreed to participate, and all of the patients completed the QoL scales and pedometer measurement during the preoperative period. Of those, 20 dropped out at 6 months, while 4 additional

patients declined to use the pedometer at 12 months (Fig. 1). The main reason for dropping out was the inconvenience of wearing a pedometer. In total, 38 patients completed all the questionnaires and pedometer measurements. The age distribution of the study completers and those who withdrew (hereafter, dropouts) did not differ significantly (60.9 and 61.5 years old, respectively; p [ 0.05). At the pre-THA period, the mean number of steps and BMI did not differ significantly between the completers and dropouts. The mean number of steps was 4,282 for the completers and 4,632 for dropouts (p [ 0.05), while the mean BMI was 23.1 for completers and 23.0 for dropouts (p [ 0.05). In addition, the mean BMI based on self-reported data did differ significantly from the mean BMI based on medical records (p [ 0.05). However, the OHS scores differed significantly between the two groups; the mean was 29.9 for the completers and 34.9 for dropouts (p = 0.014). The demographic characteristics of the patients and the control group are summarized in Table 1. By design the mean age of the patients was similar to that of the healthy controls. The mean BMI and prevalence of comorbidities were also similar in both groups (Table 1). Thirty-three patients underwent unilateral THA, and one patient had a post-surgical complication of hip dislocation. Improvements in QoL scores The QoL of patients measured by SF-8 (MCS and PCS) and OHS improved significantly from the preoperative period to 12 months post-THA (Table 2). Of these four scales, the magnitude of improvement was greatest for OHS. During the preoperative period, the patient group had significantly lower QoL scores than the control group. By 6 months, the patient group still had a significantly lower SF-8 PCS score compared with the control group. At 12 months post-THA, all mean scale scores were similar between the patient and control groups (Tables 2, 3).

Fig. 1 Patient disposition

Pre-operative data (n=62) 6 months

Dropouts (20) Refused to use the pedometer (20)

12 months

Dropouts (4) Refused to use the pedometer (4)

Complete data for all three times (38 women)

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Table 1 Characteristics of the patients prior to THA and the control subjects THA n = 38 (%)

Controls n = 38 (%)

p value*

60.9 ± 9.1

61.5 ± 10.9

ns

43–82

41–83

Age (years) Mean ± SD Range BMI (kg/m2) Mean ± SD

23.0 ± 3.6

23.0 ± 3.2

Range

17.8–32.5

17.0–33.8

Living with a family member

33 (86.8 %)

33 (86.8 %)

Living alone

5 (13.2 %)

5 (13.2 %)

Yes

5 (13.2 %)

13 (34.2 %)

No

33 (86.8 %)

25 (65.8 %)

23 (60.5 %) 11 (28.9 %)

25 (65.8 %) 13 (34.2 %)

ns

Living arrangement ns

Employment 0.032

Comorbidities Yes Hypertension Dyslipidemia

6 (15.8 %)

10 (26.3 %)

Diabetes mellitus

3 (7.9 %)

4 (10.5 %)

ns

THA Unilateral

33 (86.8 %)

Bilateral

5 (13.2 %)

Complication Yes

1 (2.6 %)

Hip dislocation

1 (2.6 %)

* t test

Improvement in physical activity levels The pedometer data showed that all the THA patients and healthy controls wore the pedometer every day. The mean hours of pedometer use per day was 14.4 h, ranging from 10.6 to 18.5 h per day during the 7-day pedometer study period. The number of steps improved significantly across the three time points (Fig. 2a) and was accompanied by a significant increase in the moderate intensity of PA (Fig. 2b). In terms of activity level, light and moderate PA improved significantly at 1 year after THA, while no improvement was observed for vigorous PA (Table 4). When improvement was measured by effect size, the largest effect was found in moderate PA between pre-THA and 12 months post-THA, followed by moderate PA between pre-THA and 6 months post-THA (Table 4). When PA was compared with that in the healthy control group, all PA level indicators for THA patients were significantly lower pre-THA (Table 5). By 6 months postsurgery, with the exception of light PA, the differences in

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all PA indicators between the patient and control groups remained significant. By 12 months, only the duration of vigorous PA remained significantly different between the two groups (Table 5). Figure 3 shows the relative improvement of PA function in THA patients. At pre-THA, light PA was already 78 % of the healthy controls and improved to 90 % at 12 months. In contrast, moderate PA was 27 % of the controls and rose to 77 % by 12 months, and vigorous PA remained low throughout the study period (Fig. 3). Correlations between QoL and PA During the preoperative period, none of the PA indicators were correlated with the QoL scales (data not shown). At 6 months after THA, the daily number of steps and PA intensity were weakly correlated with SF-8 physical summary score and OHS scores (Table 6). Additionally, longer duration of moderate and vigorous PA was significantly correlated with better QoL scores with the exception of a lack of correlation between the duration of vigorous PA and mental summary score. By 12 months, most of the significant correlations between PA and QoL had disappeared. Nevertheless, the amount of moderate PA remained significantly associated with the SF-8 physical summary and the OHS score, while vigorous PA remained associated with the OHS score (Table 6).

Discussion To our knowledge, this prospective study is the first to report the postoperative improvement of PA levels among THA patients as well as the association between PA level and QoL up to 1 year post-THA. Our study described the recovery process of PA levels in the first year after THA and showed continuous improvements in all the PA indicators except for vigorous PA throughout the year. By 1 year post-THA, most of the PA levels became 80 and 90 % of those in the healthy comparison group. Relative recovery of PA level in our THA patients corresponds with the relative recovery of functional capacity in the meta-analysis. According to the metaanalysis of recovery of functional capacity, measured by walking speed, after THA, functional capacity had generally recovered to 80 % of that of controls at 6–8 months postoperatively [7]. The similarity of recovery rates between functional capacity and PA shows concurrent validity of our findings. Nevertheless, the studies in the meta-analysis have not measured actual daily activity of THA patients in the home situation, and only a few studies reported that investigated the recovery of functional capacity longer than 8 months after surgery [7].

41.13 ± 5.96

48.88 ± 6.11 29.9 ± 5.89

52.89 ± 5.25 19 ± 5.86

47.85 ± 4.72

6 M post-THA (mean ± SD)

47.85 ± 4.72 52.89 ± 5.25 19 ± 5.86

\0.001 \0.001

6 M post-THA (mean ± SD)

\0.001

p value

53.63 ± 3.67 16.2 ± 4.48

48.99 ± 4.51

12 M post-THA (mean ± SD)

41.13 ± 5.96

48.88 ± 6.11

Physical CS

Mental CS

SF-8

Pre-THA (mean ± SD)

52.27 ± 6.19

49.63 ± 5.31

Control group (mean ± SD)

0.02

\0.001

p value

52.89 ± 5.25

47.85 ± 4.72

6 M post-THA (mean ± SD)

52.27 ± 6.19

49.63 ± 5.31

Control group (mean ± SD)

NS NS

48.88 ± 6.11 29.9 ± 5.89

41.13 ± 5.96

Pre-THA (mean ± SD)

53.63 ± 3.67

48.99 ± 4.51

12 M post-THA (mean ± SD)

NS \0.001

NS

p value

p value

Table 3 Changes in the mean scores of SF-8 from preoperation to 12 months after THA and control

M month, SF-8 short form 8, OHS Oxford hip score, CS component summary score

Mental CS OHS

Physical CS

SF-8

Pre-THA (mean ± SD)

Table 2 Changes in the mean scores of the SF-8 and OHS from preoperation to 12 months after THA

52.27 ± 6.19

49.63 ± 5.31

Control group (mean ± SD)

53.63 ± 3.67 16.2 ± 4.48

48.99 ± 4.51

12 M post-THA (mean ± SD)

NS

NS

p value

\0.001 \0.001

\0.001

p value

-0.14 0.47

-0.24

6 vs. 12 M

-0.55

-1.43

Pre vs. Con

0.12

-0.38

6 M vs. Con

Effect size

-0.66 1.86

-1.13

Pre vs. 6M

Effect size

0.37

-0.14

12 M vs. Con

-0.78 2.33

-1.32

Pre vs. 12 M

Physical activity and QoL among THA patients 49

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K. Fujita et al.

Fig. 2 a Improvement in the number of steps in THA patients from pre-THA to 6 and 12 months post-THA with the control group as a reference. b Improvement in the PA in THA patients from pre-THA to 6 and 12 months post-THA with the control group as a reference.

One-way repeated-measures ANOVA with Bonferroni p value correction for multiple comparisons and two-way repeated-measures ANOVA for two age groups

Although pedometers have been used to measure actual daily activity in THA patients in previous studies [12, 14], data were collected at only a single time in these studies. Notably, the delay between the operative procedure and the subsequent measurement of PA levels was C6 months in the US study [12] and C10 years in an Irish study [14]. The strength of our study is that it is a prospective evaluation of the improvement of the number of steps and PA intensity, measurements of actual daily activity, from 6 months to 12 months after surgery. This information on the recovery process will be useful for preoperative orientation and patient education. For example, specific information on daily activity can be given preoperatively so that patients can have realistic expectation for recovery. Vigorous PA is not recommended for THA patients, and, in this study, the vigorous PA level in the THA group was less than one-fourth of that of their healthy counterparts. Although increased PA levels in THA patients are presumed to increase the risk of joint loosening, this concern is not supported by the evidence. Indeed, a study by Dubs et al. [21] showed that THA patients who played sports had a lower risk of joint loosening than those who did not. More recent evidence suggests that patients’ PA levels were not associated with polyethylene wear [14]. Thus, multiple factors other than the PA level seem to affect joint wear. As technology continues to advance in THA, monitoring complication rates as well as PA levels is necessary to improve QoL in THA patients. Preoperative demand has been shown to be a valid indicator of the patient PA level post-THA [22]. In this study, the authors classified patients’ expected PA level

according to the Lahey Clinic Demand Categories: (1) sedentary, (2) household ambulatory, (3) community ambulatory, (4) no walking limit, and (5) sports/heavy work. They found that preoperative demand, patient’s age, weight, bone stock, and health were predictors of postTHA activity. As patient activity varies greatly before and after THA, preoperative demand may require further refinement. The significant improvement in health-related QoL noted in our patients is consistent with that reported in earlier prospective studies [1–4]. Our study found that QoL scores tended to plateau at 6 months post-THA, while PA levels continued to improve throughout to 12 months. This may reflect the ceiling effects of the QoL scales.

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Implication for clinical practice While a number of studies have assessed the QoL of THA patients, PA levels have received much less attention. In recent years, the number of younger patients receiving THA has been increasing, and patients’ expectations for postoperative function will change accordingly. To meet these increasingly varied expectations, preTHA assessment is important to understand each patient’s physical activity and expectations for postoperative activity. A pre-existing scale could be used to measure changes in physical activities, including sports, work, and leisure [9, 10]. Self-reported PA [9, 11] as well as objectively measured PA [12, 14] have shown great variations before and after THA. Our study was limited to women; nevertheless, some

107 ± 49

16 ± 18

1±3

Light PA (min/day)

Moderate PA (min/day)

Vigorous PA (min/day)

1±5

32 ± 49

123 ± 42

5,657 ± 2,106

6 M post-THA (mean ± SD)

NS

0.04

0.007

0.001

p value

1±5

32 ± 49

123 ± 42

5,657 ± 2,106

6 M post-THA (mean ± SD)

3±4

46 ± 50

125 ± 42

6,163 ± 2,410

12 M post-THA (mean ± SD)

NS

0.001

NS

0.017

p value

1±3

16 ± 18

107 ± 49

4,632 ± 2,246

Pre-THA (mean ± SD)

3±4

46 ± 50

125 ± 42

6,163 ± 2,410

12 M post-THA (mean ± SD)

-0.02

-0.87

\0.001 NS

-0.33

-0.45

Pre vs. 6M

107 ± 49

16 ± 18

1±3

Moderate PA (min/day)

Vigorous PA (min/day)

4,632 ± 2,246

Light PA (min/ day)

No. of steps (steps/day)

Pre-THA (mean ± SD)

12 ± 19

60 ± 42 1±5

32 ± 49

\0.001 0.001

123 ± 42

0.016

5,657 ± 2,106

7,228 ± 3,132 \0.001 137 ± 55

6 M post-THA (mean ± SD)

p value

Control (mean ± SD)

12 ± 19

60 ± 42

137 ± 55

7,228 ± 3,132

Control (mean ± SD)

0.001

0.01

NS

0.012

p value

Table 5 Number of steps and mean level of physical activity per day for THA patients and healthy persons

PA physical activity

3±4

46 ± 50

125 ± 42

6,163 ± 2,410

12 M post-THA (mean ± SD)

12 ± 19

60 ± 42

137 ± 55

7,228 ± 3,132

Control (mean ± SD)

0.003

NS

NS

NS

p value

-3.8

-2.4

-0.6

-1.16

Pre vs. Con

-2.16

-0.57

-0.32

-0.75

6 M vs. Con

Effect size

-0.2

-0.28

-0.04

-0.24

6 M vs. 12 M

Effect size

0.005

\0.001

p value

One-way repeated-measures ANOVA with Bonferroni p value correction for multiple comparisons and two-way repeated-measures ANOVA for two age groups

4,632 ± 2,246

No. of steps (steps/day)

Pre-THA (mean ± SD)

Table 4 Number of steps and mean level of physical activity per day for THA patients

-2.25

-0.28

-0.28

-0.44

12 M vs. Con

-0.37

-1.63

-0.36

-0.68

Pre vs. 12 M

Physical activity and QoL among THA patients 51

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K. Fujita et al.

Fig. 3 Degree of relative recovery for PA indicators compared with healthy controls

Table 6 Spearman’s correlations among the SF-8, OHS and physical activity 6 and 12 months after THA Month

Step

Duration of physical activity according to intensity level Light PA

Moderate PA

Vigorous PA

6M

conducted were women. Men tend to be more active than women, and future studies need to include men with a variety of backgrounds. Further, study dropouts had worse OHS scores than completers although PA indicators did not differ significantly between these two groups. In future studies, a larger sample is necessary to examine the association between QoL and physical function. Age-matching was used to recruit the healthy control group. However, they may have more interest in PA and be more active than the average citizen, as the purpose of the study was to measure the PA level. A questionnaire survey of PA in the community may provide an unbiased estimate of physical activity. Seasonal variations in activity levels may have had some impact on the PA levels in the study population. However, the study region has a moderate climate. As the pre-THA period was conducted in winter, the 12-month follow-up also coincided with winter. Therefore, the improvements in PA levels at 12 months post-THA were not affected by seasonal temperature variations.

SF-8 Mental CS

0.090

0.009

0.347**

Physical CS

0.344*

0.045

0.525**

0.432*

-0.325*

-0.028

-0.647**

-0.474*

OHS

0.176

12 M SF-8 Mental CS

0.107

0.041

0.215

Physical CS

0.186

0.032

0.321*

0.266

-0.218

0.007

-0.481**

-0.389*

OHS

0.136

** p \ 0.01, * p \ 0.05

of the women engaged in vigorous PA, such as running. Although patient advice should be evidence-based, evidence for the risk of loosening with increasing levels and intensity of PA is lacking for the new generation of artificial joints [22, 23]. For now, the general guidelines remain useful for patient education, but patients need to be informed about the uncertainty of risk associated with the new technology.

Conclusions The current study examined changes in PA measured by a pedometer, as well as changes in QoL in women undergoing THA. By 12 months after THA, the QoL scale scores in the patient group became comparable with those of the healthy control group. Other than one exception, all physical activity indicators in the patient group improved significantly over time and reached 80–90 % of those in the control group at 12 months after THA. Acknowledgments The authors would like to express their appreciation for the cooperation extended by the study participants and the staff at the Department of Orthopedic Surgery at Saga University Hospital. Conflict of interest The authors have no conflicts of interest to declare with respect to employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and research grants or other funding.

Limitation of the study Our sample size was small, and patients were enrolled at one hospital in Japan. Thus, the homogeneity of the study sample may have resulted in less variation in the outcome compared with the other pedometer studies [12, 14, 24]. However, the mean number of steps in our sample is comparable with that in prior studies. Our sample was also limited to women because over 80 % of the patients attending the orthopedic department where this study was

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