Research Article

The Mediating Role of Functional Limitations Between Recurrent Falls and Knee Osteoarthritis: An Observational Study Based on CHARLS 2015

DOI:

10.3791/70456

⸱

June 16th, 2026

 ,  ,  ,  ,  ,  ,  ,  ,  ,  ,  , 
1International Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, 2School of Orthopedics, Henan University of Chinese Medicine, 3School of Traditional Chinese Medicine, Hubei University of Chinese Medicine, 4General Medicine Department, Hospital of Chengdu University of Traditional Chinese Medicine

* These authors contributed equally

In This Article

Summary

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This cross-sectional observational mediation analysis suggests that functional limitations partially mediate the association between recurrent falls and knee osteoarthritis, highlighting the importance of fall prevention and functional maintenance in middle-aged and older adults.

Abstract

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Studies on the relationships among functional limitations, recurrent falls, and knee osteoarthritis remain limited. This cross-sectional observational study examined the associations among recurrent falls, functional limitations, and knee osteoarthritis and evaluated whether functional limitations mediated the relationship between recurrent falls and knee osteoarthritis. After excluding participants younger than 45 years and those with missing data for core variables and covariates, 2,278 participants from the CHARLS 2015 survey were included in complete-case analysis. Spearman correlation analysis was used to assess the correlations among recurrent falls, functional limitation score, and knee osteoarthritis. Because knee osteoarthritis was treated as a binary outcome, multivariable logistic regression was used to evaluate its association with recurrent falls. Mediation analysis was performed within a bootstrap mediation framework based on a linear mediator model and a logistic outcome model, with recurrent falls as the independent variable, functional limitation score as the mediator, and knee osteoarthritis as the dependent variable. Recurrent falls were significantly associated with higher odds of knee osteoarthritis in the adjusted model. After the functional limitation score was added to the model, recurrent falls remained significantly associated with knee osteoarthritis, and the functional limitation score was also significantly associated with knee osteoarthritis. Bootstrap mediation analysis showed a total effect of 0.093 (95% CI: 0.050–0.138), a direct effect of 0.079 (95% CI: 0.037–0.123), and an indirect effect through functional limitations of 0.014 (95% CI: 0.006–0.023), accounting for 14.92% of the total effect. These findings support a statistically significant mediation pattern in which functional limitations serve as an intermediate factor in the association between recurrent falls and knee osteoarthritis. These results highlight the importance of integrating fall-risk assessment and functional status evaluation into health management for knee osteoarthritis in middle-aged and older adults.

Introduction

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Knee osteoarthritis (KOA) is a common degenerative joint disease that usually manifests as knee pain, limited mobility, and joint stiffness1,2,3. With the prolonged course of the disease, patients often experience dysfunction of the knee joint, and in severe cases, they even lose the ability to perform daily activities4,5. Knee osteoarthritis has a high epidemiologic burden worldwide, and it is especially common in the elderly population6,7,8. It is estimated that approximately 13% of individuals aged 60 years or older have knee osteoarthritis, and its prevalence tends to increase significantly with age9. Knee osteoarthritis imposes a significant burden on individuals, families, and society10,11. At the societal level, knee osteoarthritis not only increases healthcare resource consumption but also significantly reduces labor productivity, thereby increasing the socioeconomic burden12,13,14. Mechanistically, knee osteoarthritis is a multifactorial disease involving biological, biomechanical, inflammatory, metabolic, and post-traumatic pathways, including age-related degeneration and injury-related joint instability or abnormal loading. Therefore, it is necessary to conduct relevant studies on knee osteoarthritis to clarify its associated factors, especially modifiable factors related to mobility, joint loading, and functional decline.

Recurrent falls have received increasing research attention in recent years and are prevalent in the elderly population15,16,17. Falls not only increase the risk of injury in older adults, which may lead to conditions such as fractures or head trauma, but may also cause long-term functional impairment in older adults, leading to functional limitations and a reduced quality of life, and may also lead to the development of knee osteoarthritis18,19,20. Studies have shown that falls occur in approximately 25% of older adults each year21,22,23. In addition, as the population ages, the incidence of falls and the resulting socioeconomic costs continue to rise. This not only tests families' affordability but also places tremendous pressure on the public health system24,25. In the pathological context of knee osteoarthritis, recurrent falls are relevant not only because of acute injury, but also because fall-related pain, joint injury, gait instability, and fear of falling may reduce activity participation and alter lower-limb loading patterns26,27. Therefore, how to reduce the incidence of falls, especially to avoid recurrent falls in elderly individuals, has become an urgent issue.

Functional limitations are often related to chronic joint loading, restricted movement, and altered movement patterns. Functional limitations of the knee joint in elderly individuals may directly affect the loading capacity of the knee joint, with long-term abnormal loading and degenerative changes in the joint triggering the development of knee osteoarthritis28,29,30. Functional limitations may further influence knee osteoarthritis-related health burden by reducing periarticular muscle support, impairing dynamic knee stability, and promoting compensatory gait patterns; these changes may increase mechanical stress on cartilage, meniscus, subchondral bone, and periarticular soft tissues. In addition, studies have shown that long-term recurrent falls not only lead directly to physical injuries but also may aggravate functional limitations, which in turn affect quality of life and may lead to the development of knee osteoarthritis31,32. Therefore, functional limitations may play an important mediating role in the relationship between recurrent falls and knee osteoarthritis, and may act as a functional bridge between fall-related mobility decline and knee osteoarthritis-related health burden.

Therefore, this study aimed to examine whether functional limitations mediate the association between recurrent falls and knee osteoarthritis among middle-aged and older Chinese adults, thereby providing evidence for fall prevention and functional maintenance in knee osteoarthritis-related health management.

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Protocol

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Data
The CHARLS database is based on a survey of health, economic, and social activities in China33. All the CHARLSs received ethical approval from the Institutional Review Board (IRB) of Peking University. The IRB approval number for the main household survey (including anthropometrics) was IRB0000105211015. In the current study, the authors applied the 2015 survey. The sample consisted of 21,095 participants. Participants aged ≤45 years or with missing age information were excluded. Participants with missing data for the three core variables, recurrent falls, functional limitation score, and knee osteoarthritis, were then excluded. Finally, participants with missing covariate data were further excluded to construct a complete-case analytical dataset. All the materials and tools used for this study are listed in the Table of Materials.

Key variable indicators

Recurrent falls
Fall was a participant self-reported outcome34, which was assessed on the basis of "Have you experienced any falls since your last visit?" The participants provided binary responses, indicating either "yes" or "no." In the present analysis, participants who answered “yes” were classified as having recurrent falls, and those who answered “no” were classified as not having recurrent falls.

Knee osteoarthritis
The outcome of symptomatic knee osteoarthritis was determined if the participant answered "yes" to the first of the following questions and "knee" to the second question35 : “Are you often troubled with any body pain?” and “On what part of your body do you feel pain? Please list all parts of the body you are currently feeling pain in.” Thus, knee osteoarthritis in this study was operationalized using self-reported knee pain information from CHARLS 2015. This definition was used because, owing to the data-collection design of CHARLS 2015, radiographic assessment and physician-diagnosed knee osteoarthritis were not available in the dataset used for this analysis.

Functional limitations
Functional limitations were assessed using activities of daily living (ADL) and instrumental activities of daily living (IADL) items from CHARLS 201536. ADL items included difficulties in dressing, bathing, eating, getting in and out of bed, toileting, and controlling urination and defecation. IADL items included difficulties in housework, cooking, shopping, managing money, and taking medication. Each item was scored on a four-point scale from 1, indicating no difficulty, to 4, indicating inability to perform the activity. The 11 ADL and IADL items were summed to generate a functional limitation score ranging from 11 to 44. Higher scores indicated more severe functional limitations. The functional limitation score was treated as a continuous mediator in the mediation analysis. In addition, ADL disability and IADL disability were constructed as binary covariates. ADL disability was coded as present if the participant reported being unable to perform at least one ADL activity. IADL disability was coded as present if the participant reported being unable to perform at least one IADL activity. These two binary variables were included as covariates in the regression models, whereas the summed functional limitation score was used as the mediator.

Covariates
The covariates included sex, age, drinking status, smoking status, body mass index category, night sleep duration, depression status, cognition score, ADL disability, and IADL disability. Sex was categorized as male or female. Age was analyzed as a continuous variable. Drinking status was coded as yes if participants reported drinking alcoholic beverages, either more than once per month or less than once per month, and no if they reported no alcohol consumption. Smoking status was coded as yes if participants reported a history of smoking and no otherwise. Body mass index was categorized as underweight, normal, overweight, or obese. Night sleep duration was categorized as <6 h or ≥6 h.

Depression status was assessed using the 10-item depressive symptom scale from CHARLS 201537. The items asked whether, during the past week, participants were bothered by things that usually did not bother them, had difficulty concentrating, felt depressed, felt that everything was an effort, felt hopeful about the future, felt fearful, had restless sleep, felt happy, felt lonely, or could not get going. Each item was originally scored on a four-point frequency scale from 1 to 4. For the eight negatively worded items, responses were converted to scores from 0 to 3 by subtracting 1 from the original response. The two positively worded items, feeling hopeful about the future and feeling happy, were reverse-scored. The total depression score ranged from 0 to 30, with higher scores indicating more severe depressive symptoms. Participants were categorized into depression score <10 and ≥10 groups, with a score ≥10 indicating a higher depressive symptom burden.

Cognition score was calculated using cognition-related items from CHARLS 201538. These items included correct identification of the year, month, date, day of the week, and season; five serial subtraction tasks; and a figure-drawing task. For the serial subtraction task, participants were asked to subtract 7 from 100 in successive steps, and correct answers to the five steps were scored separately. Correct responses were scored as 1 and incorrect responses as 0. The total cognition score was calculated by summing all item scores, with a possible range from 0 to 11. Higher scores indicated better cognitive performance.

Statistical analysis
First, a complete-case analytical dataset was constructed by excluding participants younger than 45 years and those with missing data for recurrent falls, functional limitation score, knee osteoarthritis, or covariates included in the regression models. The characteristics of the study population were summarized as means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Baseline characteristics were compared between female and male participants using Student’s t-test for continuous variables and chi-square tests for categorical variables. Spearman correlation analysis was performed to examine the correlations among recurrent falls, functional limitation score, and knee osteoarthritis.

Because knee osteoarthritis was treated as a binary outcome, multivariable logistic regression was used to examine the association between recurrent falls and knee osteoarthritis. The functional limitation score was treated as a continuous mediator; therefore, linear regression was used to evaluate the association between recurrent falls and the functional limitation score. Model 1 included recurrent falls as the main independent variable and adjusted for sex, age, drinking status, smoking status, body mass index category, night sleep duration, depression status, cognition score, ADL disability, and IADL disability. Model 2 included the same covariates as Model 1 and additionally included the functional limitation score.

The mediation analysis was conducted using a bootstrap mediation framework based on a linear mediator model and a logistic outcome model. In this model, recurrent falls were defined as the independent variable, functional limitation score as the mediator, and knee osteoarthritis as the dependent variable. The mediation analysis estimated the indirect effect, direct effect, total effect, and proportion mediated. Path a represented the association between recurrent falls and functional limitation score, and path b represented the association between functional limitation score and knee osteoarthritis after adjustment for recurrent falls and covariates. The direct effect represented the association between recurrent falls and knee osteoarthritis after functional limitation score was included in the model.

Bootstrap resampling with 5,000 simulations was used to estimate the total, direct, and indirect effects and their 95% confidence intervals. The authors used 5,000 bootstrap simulations to improve the stability of confidence interval estimation for the indirect effect, which is often non-normally distributed. The mediation effect was considered statistically significant when the 95% bootstrap confidence interval did not include zero. Statistical significance was defined as a two-sided p value <0.0539.

All statistical analyses were conducted using R software version 4.4.1 on Windows 10 x64. The main R packages used included tidyverse version 2.0.0, dplyr version 1.1.4, tableone version 0.13.2, psych version 2.5.6, mediation version 4.5.1, and ggplot2 version 3.4.4. Data extraction and variable construction were performed using prespecified R scripts according to the CHARLS 2015 variable dictionary and questionnaire documentation. Reproducibility was ensured by using prespecified scripts and recording the R session information. Statistical analyses were performed by the study authors, and the analytical outputs were checked against the generated tables and figures. In addition, the statistical workflow, model selection, and main analytical outputs were reviewed by a professor with expertise in statistical methodology from the author’s university to further ensure the appropriateness and reliability of the analyses.

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Results

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Characteristics of participants
The study population was selected through the screening process shown in Figure 1. A total of 21,095 participants from the CHARLS 2015 survey were initially screened. After excluding 1,934 participants aged ≤45 years or with missing age information, 19,161 participants remained. Among them, 6,572 participants were excluded due to missing data on recurrent falls, functional limitation score, or knee osteoarthritis, and 10,311 were further e...

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Discussion

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This study examined the mediating role of functional limitations in the association between recurrent falls and knee osteoarthritis among middle-aged and older Chinese adults. The results showed that recurrent falls were associated with knee osteoarthritis and that functional limitations partially mediated this association. These findings indicate that functional decline is not only a consequence accompanying falls or knee symptoms, but also an important intermediate state linking fall history with knee osteoarthritis-re...

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Disclosures

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The authors report no conflicts of interest in this work.

Acknowledgements

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The authors thank the China Health and Retirement Longitudinal Study (CHARLS) team and all participants for providing the publicly available data used in this study.

Funding:
This work was supported by the 2025 General Program of Sichuan Administration of Traditional Chinese Medicine, Project No. 25MSZX135; the 2025 General Program of Chengdu Municipal Health Commission, Project No. 2025305; the 2025 Xinglin Scholar Independent Exploration Special Project of Chengdu University of Traditional Chinese Medicine, Project No. 330026199; and the Henan Students’ Innovation Training Program, Project No. 202510471007.

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Materials

List of materials used in this article
NameCompanyCatalog NumberComments
China Health and Retirement Longitudinal Study 2015 survey dataChina Health and Retirement Longitudinal Study, Peking UniversityNot applicablePublicly available survey dataset used for the secondary analysis. Registered researchers can access the data through the CHARLS official website.
Dplyr R PackageCRANVersion 1.1.4Used for data cleaning, filtering, recoding, and variable construction.
Ggplot2 R PackageCRANVersion 3.4.4Used for visualization and figure preparation.
Mediation R PackageCRANVersion 4.5.1Used to perform bootstrap mediation analysis based on a linear mediator model and logistic outcome model.
Psych R PackageCRANVersion 2.5.6Used for descriptive statistics and scale-related data handling.
R softwareR Foundation for Statistical ComputingVersion 4.4.1Used for data processing, variable construction, statistical analysis, regression modeling, mediation analysis, and figure/table generation.
Tableone R PackageCRANVersion 0.13.2Used to summarize baseline characteristics of the study population.
Tidyverse R PackageCRANVersion 2.0.0Used for data organization and data management.

References

$$\rightleftharpoonup{xx}$$ $$\longleftharp{xx}$$, $$\longrightharp{xx}$$,
  1. Li, Z. M., Li, M. Improvement in orthopedic outcome score and reduction in IL-1β, CXCL13, and TNF-α in synovial fluid of osteoarthritis patients following arthroscopic knee surgery. Genet. Mol. Res. 16 (3), gmr16039487(2017).
  2. Shi, X., et al. A comparison of the effects of electroacupuncture vs transcutaneous electrical nerve stimulation for pain control in knee osteoarthritis: A protocol for network meta-analysis of randomized controlled trials. Medicine. 98 (28), e16265(2019).
  3. Zeng, C. Y., Zhang, Z. R., Tang, Z. M., Hua, F. Z. Benefits and mechanisms of exercise training for knee osteoarthritis. Front. Physiol. 12, 794062(2021).
  4. Sadatsuki, R., et al. Bone marrow lesion is associated with disability for activities of daily living in patients with early stage knee osteoarthritis. J. Bone Miner. Metab. 37 (3), 529-536 (2019).
  5. O'Connell, M., Farrokhi, S., Fitzgerald, G. K. The role of knee joint moments and knee impairments on self-reported knee pain during gait in patients with knee osteoarthritis. Clin. Biomech. 31, 40-46 (2016).
  6. Issa, S. N., Sharma, L. Epidemiology of osteoarthritis: an update. Curr. Rheumatol. Rep. 8 (1), 7-15 (2006).
  7. Sun, X., et al. Osteoarthritis in the middle-aged and elderly in China: prevalence and influencing factors. Int. J. Environ. Res. Public Health. 16 (23), 4701(2019).
  8. Singh, A. K., Kalaivani, M., Krishnan, A., Aggarwal, P. K., Gupta, S. K. Prevalence of osteoarthritis of knee among elderly persons in urban slums using American College of Rheumatology criteria. J. Clin. Diagn. Res. 8 (9), JC09-JC11 (2014).
  9. Wood, A. M., Brock, T. M., Heil, K., Holmes, R., Weusten, A. A review of the management of hip and knee osteoarthritis. Int. J. Chronic Dis. 2013, 845015(2013).
  10. Tangtrakulwanich, B., Chongsuvivatwong, V., Geater, A. F. Habitual floor activities increase risk of knee osteoarthritis. Clin. Orthop. Relat. Res. 454, 147-154 (2007).
  11. Castro-Dominguez, F., et al. Literature review to understand the burden and current non-surgical management of moderate-severe pain associated with knee osteoarthritis. Rheumatol. Ther. 11 (6), 1457-1499 (2024).
  12. Leardini, G., et al. Direct and indirect costs of osteoarthritis of the knee. Clin. Exp. Rheumatol. 22 (6), 699-706 (2004).
  13. Loza, E. Economic burden of knee and hip osteoarthritis in Spain. Arthritis Rheum. 61 (2), 158-165 (2009).
  14. Summanen, M., Ukkola-Vuoti, L., Kurki, S., Tuominen, S., Madanat, R. The burden of hip and knee osteoarthritis in Finnish occupational healthcare. BMC Musculoskelet. Disord. 22 (1), 501(2021).
  15. Neyens, J. C., Dijcks, B. P., de Kinkelder, A., Graafmans, W. C., Schols, J. M. CBO guidelines to prevent accidental falls in the elderly: how can it be used in the institutionalized elderly? Tijdschr. Gerontol. Geriatr. 36 (4), 155-160 (2005).
  16. Seo, Y., Kim, K., Kim, J. S. Trends of nursing research on accidental falls: a topic modeling analysis. Int. J. Environ. Res. Public Health. 18 (8), 3963(2021).
  17. Heinimann, N. B., Kressig, R. W. Accidental falls in the elderly. Praxis. 103 (13), 767-773 (2014).
  18. Iglesias, C. P., Manca, A., Torgerson, D. J. The health-related quality of life and cost implications of falls in elderly women. Osteoporos. Int. 20 (6), 869-878 (2009).
  19. Dionyssiotis, Y., Dontas, I. A., Economopoulos, D., Lyritis, G. P. Rehabilitation after falls and fractures. J. Musculoskelet. Neuronal Interact. 8 (3), 244-250 (2008).
  20. Ribeiro, A. P., de Souza, E. R., Atie, S., de Souza, A. C., Schilithz, A. O. The influence of falls on the quality of life of the aged. Cien. Saude Colet. 13 (4), 1265-1273 (2008).
  21. Kakara, R., Bergen, G., Burns, E., Stevens, M. Nonfatal and fatal falls among adults aged ≥65 years—United States, 2020–2021. MMWR Morb. Mortal. Wkly Rep. 72 (35), 938-943 (2023).
  22. Reinoso, H., McCaffrey, R. G., Taylor, D. W. M. Mitigating fall risk: a community fall reduction program. Geriatr. Nurs. 39 (2), 199-203 (2018).
  23. Phelan, E. A., Ritchey, K. Fall prevention in community-dwelling older adults. Ann. Intern. Med. 169 (11), ITC81-ITC96 (2018).
  24. Bodrud-Doza, M., et al. Psychosocial and socio-economic crisis in Bangladesh due to the COVID-19 pandemic: a perception-based assessment. Front. Public Health. 8, 341(2020).
  25. McDaid, D., et al. Health protection in times of economic crisis: challenges and opportunities for Europe. J. Public Health Policy. 34 (4), 489-501 (2013).
  26. Belluzzi, E., et al. Conditioned media from human osteoarthritic synovium induces inflammation in a synoviocyte cell line. Connect. Tissue Res. 60 (2), 136-145 (2019).
  27. Biz, C., et al. Challenging surgical treatment of displaced articular tibial plateau fractures: do early knee radiographic features have a predictive value of the mid-term clinical functional outcomes? Orthop. Surg. 11 (6), 1149-1162 (2019).
  28. Chen, L., Zhang, Z., Liu, X. Role and mechanism of mechanical load in the homeostasis of the subchondral bone in knee osteoarthritis: a comprehensive review. J. Inflamm. Res. 17, 9359-9378 (2024).
  29. Ozeki, N., Koga, H., Sekiya, I. Degenerative meniscus in knee osteoarthritis: from pathology to treatment. Life. 12 (4), 603(2022).
  30. Ni, X., et al. Physical therapy options for knee osteoarthritis: a review. Medicine. 103 (30), e38415(2024).
  31. Pinheiro, M. M., et al. Risk factors for recurrent falls among Brazilian women and men: the Brazilian Osteoporosis Study (BRAZOS). Cad. Saude Publica. 26 (1), 89-96 (2010).
  32. Ganz, D. A., et al. Effect of the STRIDE fall injury prevention intervention on falls, fall injuries, and health-related quality of life. J. Am. Geriatr. Soc. 70 (11), 3221-3229 (2022).
  33. Zhao, Y., Hu, Y., Smith, J. P., Strauss, J., Yang, G. Cohort profile: the China Health and Retirement Longitudinal Study (CHARLS). Int. J. Epidemiol. 43 (1), 61-68 (2014).
  34. Lin, P., et al. Risk of fall in patients with chronic kidney disease: results from the China Health and Retirement Longitudinal Study (CHARLS). BMC Public Health. 24 (1), 499(2024).
  35. Wang, L., Lu, H., Chen, H., Jin, S., Wang, M., et al. Development of a model for predicting the 4-year risk of symptomatic knee osteoarthritis in China: a longitudinal cohort study. Arthritis Res. Ther. 23 (1), 65(2021).
  36. Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., Jaffe, M. W. Studies of illness in the aged: the index of ADL, a standardized measure of biological and psychosocial function. JAMA. 185, 914-919 (1963).
  37. Chen, H., Mui, A. C. Factorial validity of the Center for Epidemiologic Studies Depression Scale short form in older population in China. Int. Psychogeriatr. 26 (1), 49-57 (2014).
  38. Yu, J., Feng, Q., Yu, J., Zeng, Y., Feng, L. Late-life cognitive trajectories and their associated lifestyle factors. J. Alzheimers Dis. 73 (4), 1555-1563 (2020).
  39. Jiang, Y., Fu, J., Zhou, C., Yue, X., Liu, Y. Associations between productive engagement and intrinsic capacity and their longitudinal effects on subjective well-being among older adults: a cross-lagged panel mediation analysis. J. Nutr. Health Aging. 30 (7), 100867(2026).
  40. Yiu, J., Miller, W. C., Eng, J. J., Liu, Y. Longitudinal analysis of balance confidence in individuals with stroke using a multilevel model for change. Neurorehabil. Neural Repair. 26 (8), 999-1006 (2012).
  41. Noeske, K. E., et al. Walking self-confidence and lower levels of anxiety are associated with meeting recommended levels of physical activity after hip fracture: a cross-sectional study. Disabil. Rehabil. 47 (1), 135-141 (2025).
  42. Visschedijk, J. H., Caljouw, M. A., van Balen, R., Hertogh, C. M., Achterberg, W. P. Fear of falling after hip fracture in vulnerable older persons rehabilitating in a skilled nursing facility. J. Rehabil. Med. 46 (3), 258-263 (2014).
  43. Yosef, T., Pasco, J. A., Tembo, M. C., Holloway-Kew, K. L. Hip abductor strength predicts injurious falls and mediates the balance confidence-falls relationship: a competing risk model. J. Cachexia Sarcopenia Muscle. 17 (2), e70280(2026).
  44. Anan, M., Tokuda, K., Tanimoto, K., Sawada, T. The relationship between knee flexion excursion and mechanical stress during gait in medial knee osteoarthritis. Clin. Biomech. 112, 106180(2024).
  45. Buford, T. W., et al. Kaatsu training to enhance physical function of older adults with knee osteoarthritis: design of a randomized controlled trial. Contemp. Clin. Trials. 43, 217-222 (2015).
  46. Raghava Neelapala, Y. V., Bhagat, M., Shah, P. Hip muscle strengthening for knee osteoarthritis: a systematic review of literature. J. Geriatr. Phys. Ther. 43 (2), 89-98 (2020).
  47. Syrikas, I., Engbäck, C., Tsikandylakis, G., Karikis, I., Desai, N. Increased complications rates and inferior patient-reported outcomes following total knee arthroplasty due to post-traumatic osteoarthritis with previous fracture treatment: a systematic review. Knee Surg. Sports Traumatol. Arthrosc. 31 (10), 4124-4141 (2023).
  48. de Souza, T. S., Pereira, D. B., Hagihara, R. J., Fuzinato, C. T., Ribeiro, A. P. Effect of rehabilitation program for muscle strength, balance, and gait retraining with visual feedback in older women with and without knee osteoarthritis: a clinical trial. J. Pers. Med. 15 (12), 631(2025).
  49. Gonzalez Aroca, J., Vergara Merino, L., Meza, N., Gonzalez, C., Ramirez Araya, P., et al. Interventions for improving adherence to exercise-based treatments in people with knee osteoarthritis. Cochrane Database Syst. Rev. 2025 (7), CD016088(2025).
  50. Seeley, M. K., et al. A review of the relationships between knee pain and movement neuromechanics. J. Sport Rehabil. 31 (6), 684-693 (2021).
  51. Seeley, M. K., Park, J., King, D., Hopkins, J. T. A novel experimental knee-pain model affects perceived pain and movement biomechanics. J. Athl. Train. 48 (3), 337-345 (2013).

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Tags

Knee OsteoarthritisRecurrent FallsFunctional LimitationsMediation AnalysisLogistic RegressionSpearman CorrelationFall Risk AssessmentFunctional Status EvaluationMiddle Aged AdultsCHARLS Survey

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