• Open Access

Reasons Why Multimorbidity Increases the Risk of Participation Restriction in Older Adults With Lower Extremity Osteoarthritis: A Prospective Cohort Study in Primary Care


Address correspondence to Ross Wilkie, BSc, PhD, Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, UK, ST5 5BG. E-mail: r.wilkie@keele.ac.uk..



To determine why multimorbidity causes participation restriction in adults ages ≥50 years who consult primary care with lower extremity osteoarthritis (OA).


This was a population-based prospective cohort study of 1,053 consulters for lower extremity OA who were free of participation restriction at baseline. Path analysis was used to test proposed mechanisms by examining for mediation of the association between multimorbidity at baseline, defined by self-report and consultation data separately, and incident participation restriction at 3 years by lower extremity pain severity, obesity, locomotor disability, and depression.


Multimorbidity was associated with incident participation restriction (adjusted odds ratio [OR] 2.83, 95% confidence interval [95% CI] 2.03–3.94 for multimorbidity [self-report]; OR 1.59, 95% CI 1.15–2.21 for multimorbidity [consultation data]). The extent of mediation of the association of baseline multimorbidity, defined by self-report, and incident participation restriction was greater for severe lower extremity pain than obesity (standardized beta coefficients for indirect effect 0.032 [SE 0.015] and 0.020 [SE 0.019], respectively). The addition of depression and locomotor disability increased the amount of mediation (0.115 [SE 0.028]) and reduced the proportion explained by severe lower extremity pain (0.014 [SE 0.015]) and obesity (0.006 [SE 0.010]). Locomotor disability was the strongest mediator.


The additional impact on participation in social and domestic life that multimorbidity places on individuals with lower extremity OA appears to be mediated through further restriction of locomotor disability, as well as through depression. The results suggest that the effect of multimorbidity on the daily lives of people with lower extremity OA will be ameliorated by active management of depression and locomotor disability.