\r\n\t2) Human sexual disorders in males and females.
\r\n\t3) Psychological aspects of the human sexual response cycle and its disorders.
\r\n\t4) The therapeutic aspects.
\r\n\tThe human sexual response cycle and human sexual behavior are interrelated. How this inter-relationship and its association to normal sexual health need to be delineated. In a world torn between sex and sexually transmitted disease, clear-cut scientific information in the form of a monograph is required to educate.
\r\n\r\n\tHuman sexuality, gender identity, and sexuo-erotic orientation play great roles in human health and disease. Sex education is the need of the hour and a reflection will be timely.
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The field of entrepreneurship is defined as “…the study of sources of opportunities; the processes of discovery, evaluation, and exploitation of opportunities [1].” Entrepreneurs are “…individuals who discover, evaluate, and exploit them [opportunities] ([1], p. 217).” Entrepreneurs may be of nearly any age from school age children to older adults.
Despite the reality that there are entrepreneurs of all ages, far too many of us automatically imagine that the entrepreneur is an adult in their early 20s to mid-30s, college educated, and has launched a technological venture. One study found that the mean age for launching a company is in the late 30s to early 40s [2]. The Kaufmann Foundation [3] found that the most frequent ages of entrepreneurs in descending order in 2019 were the following: 20–34 (27.2%); 55–64 (25.1%); 45–54 (24.8%); and 35–44 (22.9%). This age breakdown reflects a change from 1996 during which it was found that as age increased, the rate of new entrepreneurs decreased. The Kaufmann Foundation is missing two age cohorts: entrepreneurs under the age of 20 and entrepreneurs 65 and older. This chapter will focus on entrepreneurs along the age continuum.
Regardless of the age of the entrepreneur, there are both common challenges and unique challenges. Furthermore, there are also common and unique opportunities. This chapter will first frame entrepreneurship from a developmental theoretical frame and then review the literature on the relationship between age and entrepreneurship. This literature review will not be exhaustive due to space limitations. After theorizing about entrepreneurship and reviewing the pertinent literature, the challenges and opportunities experienced by entrepreneurs at different ages will be described. These challenges and opportunities will be discussed not just from the lens of the entrepreneur but entrepreneurial ecosystems. Toward the end of this chapter, recommendations will be presented for entrepreneurs of specific age groups and entrepreneurship support organizations (ESOs). Next, a research agenda with specific hypotheses will also be presented for academics to include age as a key variable in research. Finally, recommendations will be formulated for entrepreneurship educators in formal and informal educational settings.
The theoretical frame in this chapter is grounded in a developmental perspective drawing upon Amartya Sen’s capability approach. Sen equates human development with the enlargement of positive freedoms [4]. A related concept of Sen’s capability approach is agency. Agency is “a person’s ability to pursue and realize the goals that he or she values…the opposite of a person with agency is someone who is forced, oppressed, or passive ([4], p. 3).” Moreover, human agency is a central concept among motivation theories [5].
This capability approach is reinforced with a lifespan developmental approach drawing upon Baltes [6]. According to Baltes [6], “Lifespan developmental psychology involves the study of constancy and change in behavior throughout the life course (ontogenesis), from conception to death (p. 611).” The behavior of focus in this chapter is entrepreneurial activity. A team of researchers [7] assert citing the body of research, “Individuals’ orientation toward entrepreneurial activities differs depending on where they stand in their lifespans (p. 1).” Our lifespans are typically measured by age and occasionally by developmental periods such as adolescence.
Yet, age is a more commonly used marker of human development. There are two categories of age: chronological and subjective. Chronological age is marked by date of birth or the number of years alive. Varying patterns of entrepreneurship have been documented regarding chronological age [8]. In contrast to chronological age, subjective age is how young or old an individual experience themselves to be [9]. Beyond chronological age, age-related factors such as a future time perspective account for changes in motivation [10]. Hence, age is objective and subjective as well as static and dynamic.
Age is not the only marker of the development of human development and entrepreneurship. It was empirically found that entrepreneurial activity varies by age, yet this relationship is mediated by perceived opportunities and perceived skills [11]. As it relates to opportunities, it was found that entrepreneurial intent among high school students was positively influenced by parents first, peers second, and the neighbors third [12]. Hence, entrepreneurs are embedded in a social context. The impact of context on the development of entrepreneurial behavior is well established [13]. Furthermore, in one study, it was empirically demonstrated that entrepreneurs embedded in a supportive social context are more likely to translate their entrepreneurial intent into an actual startup [14].
Any discussion of development circles back to the nature/nurture debate. The nature/nurture debate will not be resolved here. Yet, the evidence is clear that the chances of a child becoming an entrepreneur is increased by 60% if one of the parents is an entrepreneur [15]. This finding does not address the degree to which entrepreneurship is influenced by genetics. Obschonka [16] writes, “Recent research in behavioral genetics suggests that entrepreneurship has a substantial genetic component (p. 196).” Regardless of the relative contributions of nature or nurture, Obschonka [16] concludes that, “…adolescence is a crucial developmental phase in entrepreneurial development (p. 200).” Another period of an increase in entrepreneurial activity is job loss of individuals over the age of 50 as described by Moulton and Scott [17]: “We find that job loss shows a strong association into self-employment, particularly less desirable forms of self-employment (p. 1539).” This finding is important because it demonstrates that entrepreneurship or self-employment is not inherently desirable.
Returning to the nature/nurture debate, entrepreneurship educators assume that entrepreneurship can be learned [18]. As such, this assumption suggests that entrepreneurship can be nurtured along the age continuum. One such entrepreneurship education program targeting primary/elementary school children described the effects of such education as follows:
However, there is a dearth of literature on entrepreneurship education targeting older adults over the age of 50. Moreover, most of these programs target younger entrepreneurs [20]. Hantman and Gimmon [21] describe an entrepreneurship incubator in which 70% of the 22 participants, all of whom were 55 or older, launched a new venture over the 12-meeting training program.
It is beyond the scope here to review the body of literature on the relationship between age and entrepreneurship. The research to date is mixed regarding the relationship between age and entrepreneurship. The UK (United Kingdom) government [22] defines older entrepreneurship as any entrepreneur 50 and older.
Past research has shown an inverted U-shaped relationship between age and entrepreneurship [7]. It has also been argued that there is a negative relationship between age and engaging in entrepreneurship [11, 23]. In an empirical study examining high-growth companies, it was found that founders under the age of 25 are strongly disadvantaged at creating high growth companies with a surge in creating such companies after the age of 35 and another surge after the age of 46 until plateauing at age 60 [24]. As for business ownership, individuals over the age of 55 represent one-third of all firms although this same age cohort launches 15 percent of new firms [25].
The type of business launched also vary by age. Personal services, retail and restaurants are more likely launched by entrepreneurs in the 35–53 age cohort [25]. In contrast, entrepreneurs 55 and older are more likely to launch high-tech manufacturing, real estate, metal & machinery, and health care services [25]. Entrepreneurial ventures can be categorized into four segments: financed growth; organic growth; stable small employer; and stable micro [25]. Financed growth firms were defined as those with at least $400,000 in financing cash inflows and organic growth firms were defined as those with less than $400,000 in financing cash inflows [25]. The other segments are the following: stable small employer and stable micro. The difference is that the stable small employer is defined as having over $500,000 in expenses primarily payroll and the stable micro has no or very few employees with less than $500,000 in expenses [25]. It was found that younger entrepreneurs 35 and under were less likely to own financed growth and stable small employer ventures [25]. Yet, the 35–54 age cohort were overall overrepresented across all firms based upon a population comparison. Among the older entrepreneurs 55 and older, they were more likely to be in the stable small employer and micro segment [25].
As for exits, it was found that “a founder at age 50 is approximately twice as likely to experience a successful exit compared to a founder at age 30 ([24], p. 74).” Yet, founders 55 and older are the least likely to employ others although the most likely to survive [25].
Another finding emerging from the growing body of literature on age and entrepreneurship is that entrepreneurs of different ages manifest different goals related to what it means to be an entrepreneur [7]. To this point, younger and older entrepreneurs are more likely to launch ventures which are more socially oriented than middle age entrepreneurs [7]. These types of ventures fall under the category of social entrepreneurship.
There is a wide array of reasons why ventures fail to launch, why ventures fail to generate a profit, why ventures fail to survive, and why ventures fail to exit. One of the more common challenges has to do with managing the finances of entrepreneurial ventures regardless of the age of the entrepreneur. Competence in accounting practices has been found to be a challenge for entrepreneurs between the ages of 18 to 59 and a predictor of small business failure [26]. Working capital has always represented a challenge for small businesses [26]. Lack of liquidity has become even more of a challenge given the impact of COVID-19 [27]. Although this is not the only challenge, this challenge is more than likely related to the survival of the entrepreneurial venture.
A common challenge may revolve around stereotype bias and entrepreneurs especially those who are under the age of 18 and even over the age of 50. This type of bias may present roadblocks to those seeking to become entrepreneurs because they do not fit the “mental model” of the appropriate age of an entrepreneur. Related to both age groups is an increasing degree of interdependence among others. Specifically, for those entrepreneurs under the age of 18, it is likely that parental involvement will be higher. For those over the age of 50, it is likely that involvement with children and even aging parents will be higher. In fact, empirical evidence is emerging about the U-shaped curve of age discrimination in the workplace [28]. This empirical work has to be extended to entrepreneurial settings until researchers being to investigate bias and stereotyping in entrepreneurship using age as a variable in addition to the numerous studies investigating gender.
Younger and older entrepreneurs may benefit from a different set of resources. Regarding entrepreneurship, it was found that a focus on opportunity seeking is central to venture growth among entrepreneurs from 24 to 74 [29]. Of all the generations, the millennial generation is more interested in digital entrepreneurship than previous generations [33].
Regarding specific opportunity sets for entrepreneurs, it is conceivable that younger entrepreneurs have greater physical resources such as enhanced cognitive function and are also less encumbered with family and other responsibilities [24]. As for older entrepreneurs, it is conceivable that they have greater access to capital of all types including financial, social, and human [24]. Mental health is a key moderator between the age of the entrepreneur and a focus on opportunities [29]. Intergenerational entrepreneurship represents another opportunity for entrepreneurs of all ages. This ranges from launching firms together to intergenerational entrepreneurship education [30].
The role of formal and informal organizations in shaping and supporting entrepreneurship is critical [31]. Yet, the type of support may vary given the heterogeneity of entrepreneurs. Bohlmann et al. [11] found that entrepreneurs of different ages need different types of support. Furthermore, the current entrepreneurship ecosystem has been critiqued by Bohlmann et al. [11] “These programs do not accurately take the needs and motivation of different ages into account (p. 8).”
Brieger et al. [7] recommend that high quality entrepreneurship support organizations offer services appropriate for specific life phases.
As an example, Gielnik et al. [29] based upon their study on the role of mental health for maintaining a high level focus on opportunities suggest that policy makers should invest in maintaining or improving mental health and invest in increasing learning & development opportunities targeting older entrepreneurs.
Entrepreneurship research is increasingly taking a development approach. Even further, research is increasingly investigating older entrepreneurs who are 55 and older [21]. Future research ideally will draw upon a range of theories including developmental theories. Yet, researchers have eleven theoretical perspectives from which to frame future research beyond developmental theories. Eleven perspectives include the following: negative relationship personal health; rigidity; time allocation; risk propensity; discrimination; positive relationship human capital; social capital; financial capital; emotion; family obligation; and gender stereotype.
Beyond the theoretical base of future research, different research designs are recommended including cross-sectional and longitudinal designs. Given the focus on age and entrepreneurship, cohort based, and panel research designs are also worth pursuing among future researchers. The challenge for researchers may be to collaborate with researchers from other disciplines such as developmental psychology, family systems, sociology, and gerontology [32].
This line of research should go beyond age and also examine cohort effects by generation. To this point, the call for such research has been made, “It is critical that scholars of international entrepreneurship explore millennial entrepreneurs and contrast them across generations and countries ([33], p. 9).” Given the social context of younger and older entrepreneurs in particular, intersectionality as a construct is warranted [34].
This research should be grounded in qualitative, quantitative, mixed methods and even deploy big data analytic models. Much of the research should be hypothesis driven but not all of the research due to the nascent aspects of the nexus between age and entrepreneurship as well as generation and entrepreneurship. The following hypotheses represent a starting point to engage researchers in contributing to the dearth on aging and entrepreneurship. These hypotheses are by no means exhaustive.
H1: There are differences in entrepreneurial intent among entrepreneurs across the age continuum.
H2: There are differences in entrepreneurial motivation among entrepreneurs across the age continuum.
H3: There are differences in “push” and “pull” factors among entrepreneurs across the age continuum.
H4: There are differences in opportunities in entrepreneurial financing among entrepreneurs across the age continuum.
H5: There are differences in entrepreneurial exits among entrepreneurs across the age continuum.
It has previously been mentioned that the ideal entrepreneur and most entrepreneurship education program are not inclusive by age. In fact, they target younger entrepreneurs often under the age of 30. Following this trend, there appears to be a lot of focus on weaving entrepreneurship education into primary/elementary school and secondary/high school not to mention colleges/universities. These efforts should continue but ought to be expanded to include other age groups over the age of 30 up to retirement age or older.
If indeed entrepreneurship educators offer targeted entrepreneurship curricula that is age appropriate, then this education ought to also embrace an inter-generational element rather than “segregating” the target audiences by age cohorts. Yet, the case can be made for exclusive entrepreneurship education targeting specific age cohorts given the unique challenges and opportunities facing entrepreneurs at different ages and developmental periods.
The case for targeting specific age cohorts and even generational cohorts can be further subdivided into types of entrepreneurs within a given age cohort and generational cohort. As an illustration, it was found that there are eight types of entrepreneurs in the Baby Boom Generation (born between 1946 and 1964) [35]. This typology categorizes entrepreneurs into these categories or types: new versus existing, new opportunity versus new necessity, full-time versus part-time, and incorporated versus unincorporated entrepreneurs [35]. The author of this study argues “Understanding baby boomer entrepreneurs better and assisting them to develop entrepreneurship could be an effective strategy for our aging population ([35], p. 70).”
The recommendations set forth for entrepreneurs are presented from the lens of offering tailor made recommendations for different age groups across the developmental continuum.
School age entrepreneurs are deeply embedded in a family context and increasingly a school context with a rise in entrepreneurship educational programs targeting school age entrepreneurs. The degree to which these ventures are actually family firms is subject to further discovery, but the role of parents, other relatives and others is critical to the success of school age entrepreneurs. The current legal and regulatory system not to mention societal norms may impose unique barriers for school age entrepreneurs because they have not achieved the age of majority. Hence, stakeholders in the entrepreneurship ecosystem should continue to design and deliver tailored solutions for school age entrepreneurs while at the same time advocating to relax some legal and regulatory barriers.
College age entrepreneurs are increasingly warmly embraced by colleges and universities which offer degree and certificate programs in entrepreneurship. These efforts should continue along with the hackathons and business plan competitions. Likewise, research should continue involving college age entrepreneurs yet educational, programming and research investments need to be more inclusive of other age groups beyond the college age entrepreneurs. In most nations, college attendance and graduation are the exception not the rule. As such, attention should be paid to those who are college but decide not to attend college and start ventures in the skilled trades, retail, and food/beverages as well as gig workers.
Young adult entrepreneurs have decided to choose a particular path in life regarding their occupational identify and way to earn an income. At some point, during young adult, these entrepreneurs will make a commitment as a partner and even add the role of a parent. As such, greater attention is warranted to look at the varying roles for young adults and how they balance the tasks associated with these roles as well as the challenges of launching a new venture often without steady cash flow to ensure survival.
Middle age entrepreneurs are often ignored by the entrepreneurship ecosystem except to include them as mentors and financiers. These entrepreneurs often select entrepreneurship after some adverse life event ranging from a health event to a job loss event. Hence, programming ought to focus upon not just launching a venture but also managing grief and other emotions associated with a sudden loss of stability. Similar to young age entrepreneurs, these middle age entrepreneurs with aging parents may be part of the “sandwich generation” requiring different types of programming, support, and advocacy.
Older age entrepreneurs are nearly invisible in the entrepreneurship ecosystem as participants. Proactive steps must be taken to include older entrepreneurs to counter the bias and stereotyping which occurs among older entrepreneurs. This step will require that leaders and decision makers in the entrepreneurship ecosystem look at their own biases and stereotypes and rid their organizations of such biases which become part of the culture, policies, and procedures.
Although these recommendations are presented as if they are separate, they are not. Leading organizations dedicated to enhancing entrepreneurship along the lifespan should seek to be “friendly” and “serve” entrepreneurs of all age or differentiate based upon serving entrepreneurs of a certain age group.
Furthermore, the designers, funders and evaluators of entrepreneurship programs targeting entrepreneurs at various ages must also consider the differences among the opportunity versus the necessity entrepreneurs. This categorization is similar to the push/pull framework [36]. This framework suggests that some entrepreneurs are pushed into entrepreneurship for such reasons as a lack of other career alternatives and others are pulled into entrepreneurship to pursue opportunities.
Entrepreneurship is all too often considered a more viable career option for those who are younger. Yet, as discussed above, the empirical evidence including a meta-analysis conclude that the opposite is true. Specifically, older entrepreneurs are more likely to succeed than younger entrepreneurs [37]. A central theme throughout this chapter is to challenge some assumptions that the general public, the media, academics and other stakeholders in the entrepreneurship ecosystem have about who is an entrepreneur, who seeks to be an entrepreneur out of necessity or opportunity seeking, and who should be served by entrepreneurship support organizations. The empirical evidence suggests a quite different picture that what is imagined in the eyes of most about the prototypical entrepreneur.
Fundamentally, entrepreneurship is a choice that individuals make at various stages of their life’s journey. This choice sometimes arises out of identifying an opportunity, sometimes arises out of needing to earn income, and sometimes arises out of the existential need to “chart your own course.” Regardless of the origins of the choice, entrepreneurship may occur at nearly any age from 10 to 100. The age and generational diversity of entrepreneurs is a reality that must be embraced by policy makers, entrepreneurship educators, entrepreneurship support organizations, and entrepreneurship researchers. Embracing the age and generational diversity of entrepreneurs begins with you and your beliefs about who aspires to and currently is an entrepreneur.
The authors declare no conflict of interest.
Osteoarthritis (OA) is a chronic degenerative joint disease of dynamic pathology with multiple etiologies. It involves progressive process of softening, loss of articular cartilage, subchondral bone sclerosis, development of osteophytes, and cyst formation [1].
Knee OA is the most common arthritic disease among all joints; however, there is no available drug treatment today that hinders the progression of this disease process. There are many reasons for this, including the lack of understanding of what worsens the disease process and the heterogeneity of the patient population. There are considerable differences in the course of the disease [2].
The median age for diagnosis of Knee OA is 55 years, and usually people live about 30 years suffering the disease [3]. As there is no known curative treatment for OA till now, treatments aim at improving function as well as reducing pain. Systematic reviews (SR) are a useful research method to analyze the efficacy of knee OA treatments; however, most of these reviews have not discussed the long-term risks associated with various treatment modalities. The cause for that is most studies follow patients for short time periods. There are missing data in the literature owing to the fact that most of these studies are short-term studies, thus giving a false impression about the correct data concerning short-term improvement; especially, OA is a chronic condition needing long-term studies to correctly estimate the degree of pain improvement.
Approximately 30–65% of the risk of OA is genetically determined [4].
Obesity has long been known as a risk factor for knee OA [3]. A recent meta-analysis also showed that increased BMI added to the increased risks to radiographic and/or clinical OA picture [5].
OA usually contributes to decreased activity associated with aging, secondary to diminished function and pain, thus consequently impairing quality of life. It is well established that pain due to OA, swelling, or stiffness can make it difficult for individuals to perform simple daily living activities [6].
Researches on the role of special diets in OA have been evolving. High dietary fiber intake has been associated with lower risk of developing moderate to severe knee pain over time. Results from two prospective cohort studies also showed that increased total fiber intake was related to lower risk of symptomatic knee OA, but its association with radiographic knee OA is still not evident [7]. Another study found that increased soy milk intake was associated adversely with prevalence of radiographic knee osteophytes [8]. Finally, higher intake of Mediterranean diet was associated with lower prevalence of radiographic and clinical KOA [9].
The patient usually experiences knee pain and any three of the following to diagnose clinical OA of the knee: [1] tenderness on one or more knee compartments; [2] crepitus on active motion in at one or more knee compartments; [3] morning stiffness usually less than 30 minutes, according to WOMAC scale; [4] no warmth on knee examination; [3] age more than 50 years; or [5] osteophytes in one or more knee compartments [10].
Although OA is not curable, a variety of treatment modalities are available to improve symptoms. Main elements include pain management maneuvers, education, changing lifestyle physical activity (PA), and weight reduction in case of overweight. Although total joint arthroplasty (TJA) is considered a cost-effective treatment for people with OA, TJA should only be considered after failure of conservative treatments. Since OA is a chronic disease, a key element in the nonsurgical management of knee and/or hip OA is self-management. Self-management interventions allow patients to improve their skills in taking care of themselves and to improve skills to navigate the health care system [11].
The shape of the bone may add to the risk of OA as had been described primarily in the hip joint. The association between OA and muscle strength may vary depending on the muscles and joints being studied. In an examination of anterior cruciate ligament (ACL) injured knees, high thigh muscle cross-sectional area and high muscle/fat ratio had a protective effect against KOA prevalence. Deformities of the knee are a strong predictor of knee OA disease progression [12].
Health education should be considered as a basic element of effective self-management interventions. Health education should include education about OA and its treatment options, exercise and pacing of PA, and weight reduction. This information should be tailored to the person’s illness perception and educational capability. In addition, goal setting is a widely used behavioral change technique in many fields, especially in health care. Goal setting is associated with positive impact on behavior at both shorter and longer terms [13]. Behavioral monitoring of outcomes (e.g. amount of PA, weight and achievement of goals).
Symptoms of OA are usually managed by either pharmachological or nonpharmachological protocols; joint replacement surgeries are considered in advanced cases. Analgesics remain the keystone of pharmacological treatment for OA symptoms, including paracetamol, topical and oral nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. However, benefits from paracetamol and opioids are minimal, and NSAIDs are not ideal for many patients because they have many side-effects. Intra-articular therapies such as corticosteroids are also commonly used, though usually with short-term benefits. Pharmacological drugs include the following.
It is usually used for the treatment of pseudogout and gout. Colchicine is not recommended for treatment of OA nowadays. Synovial fluid in OA usually contains basic calcium phosphate (BCP) crystals especially hydroxyapatite crystals (detected in the cartilage of nearly all affected joints at the time of joint replacement surgeries). Positive correlations have been found between synovial fluid BCP crystal levels and radiographic severity of OA [14].
Hydroxychloroquine has been used in in patients with inflammatory OA of hand joints with some suggested evidence of benefits, probably because it may have a role in treating rheumatoid arthritis (RA) synovitis and an acceptable safety profile. It has immunomodulatory effects and was considered to potentially treat OA due to Toll-like receptor (TLR) signaling inhibition, as TLRs are upregulated in OA cartilage and may have a role in cartilage breakdown
A mixture of pharmacologic and nonpharmacologic therapies can manage OA symptoms as there is currently no available disease-modifying therapy till now, so treatment depends on symptomatic slow-acting drugs for OA (SYSADOAs) as an important category in the pharmacologic therapy tools for OA that have been demonstrated to alleviate the symptoms of functional impairment and pain, with some additional evidence of a disease-modifying effect on the long run [16]. The SYSADOAs class comprises different elements, including chondroitin, glucosamine, diacerein, and avocado soybean unsaponifiables (ASU), and there are some clinical data supporting their efficiency. Placebo-controlled trials of SYSADOAs treatment lasting up to 3 years in more than one Meta-analyses provide evidence that prescribing grade crystalline glucosamine sulfate (GS), chondroitin sulfate (CS), and diacerein has mild to moderate benefits in patients with OA [17].
Numerous meta-analyses and RCTs have been conducted to assess the efficacy and safety of Intra-articular hyaluronic acid (IAHA), with mixed results and conclusions support the fact that IAHA injection is considered a suitable alternative local treatment option providing symptomatic benefit without the systemic adverse effects that may be associated with IA corticosteroids. IAHA is considered to have a positive effect on pain and joint function. A meta-analysis comparing the effectiveness of pharmacological interventions for knee OA found that IAHA is considered an effective therapy. IAHA is also demonstrated to have a longer lasting effect on function and pain compared with IA corticosteroids, lasting up to 6 months [18].
Multiple courses of IAHA can cause long-term beneficial outcomes, including reduction in analgesics used and delay in the need for joint replacement surgeries [19] still found regarding the risk benefit of IAHA. However, controversy about lack of agreement among international guidelines regarding the use of IAHA for the management of symptomatic knee OA still exists [20].
The safety of IAHA has been evaluated in eight meta-analyses of RCTs comparing IAHA to IA placebo. However, a Cochrane review of 76 RCTs was unable to conclude a definitive report on the safety of HA due to limitations concerning sample size; however, no major safety issues were found, in addition, IAHA demonstrated similar efficacy to systemic forms of medical interventions, with more local reactions but fewer systemic adverse effects [21].
Evidence suggests that exercise is one of the core therapies for OA to improve function and pain. The degree of response varies according to the type of exercise (e.g. aerobic, strengthening, etc.). Little is known about the relative effeciency of different exercise forms [22].
The comparisons were seen between strengthening exercises and mixed exercises versus usual care. For pain, function, and performance, all types of exercise were significantly better than usual care. The largest effect was observed for aerobic and mind-body exercises for function and pain. Strengthening and flexibility exercises had a moderate score, whereas mixed exercise gave the minimum score for all outcomes and was significantly less effective than aerobic or mind-body exercise for pain. The ranking mainly corresponded to the magnitude of the score shown by each exercise. Aerobic exercises were the best-ranked for performance and pain, whereas mind-body was also the best-ranked for self-reported pain and function. Strengthening and flexibility/skill generally received mid-level rankings while mixed exercises were the least ranked exercise [23].
It is confirmed that exercise is still important for people suffering from hip and knee OA for outcomes of performance function, pain. In additon, it was found that mind-body and aerobic exercise have the largest score for improvements in function and pain; strengthening and flexibility exercises improve multiple outcomes to a varying degree [23]. Older age is a well-known risk factor for OA; women are more likely to develop hand, foot, and knee OA compared to men [4].
Varus thrust increased the odds of worsening medial bone marrow lesions (BMLs) and medial cartilage loss as well as the odds of incident medial BMLs of the knee among those with KOA and those with increased risk of Knee OA according to the Multicenter Osteoarthritis Study (MOST) [24].
It was found that aerobic exercises have similar effects to mind-body exercises for controlling pain. Mind-body exercise such as yoga and tai chi can be characterized as mild to moderate intensity exercise performed with an intentional awareness (mindfulness) on breathing and slow controlled movement [25]. Although the underlying mechanism is not clear, the effect of both mind-body and aerobic exercises may be related to the possibility that these exercises affect the altered central nervous system such as central pain sensitization, mood disorders, and sleep disturbance. Pain experience is the result of interactions between these central failure and peripheral pain mechanisms, as aerobic and mind-body exercise can influence both central and peripheral pain mechanisms. There is no satisfactory explanation for the poor effect of mixed exercise, particularly when considering that there are many domains of physical impairment in people with OA [23].
So far, NSAIDs, symptomatic slow-acting drugs for OA, analgesics, bone-acting agents, putative disease-modifying agents, and agents for intra-articular injection including HA and corticosteroids have been used as pharmacological agents for treating OA. However, it has been reported that these agents are not efficient against the main cause of OA, may cause some side effects, and are not adequate for the long-term management of OA. NSAIDs are the most commonly used drugs for the management of OA. They showed moderate improvement against OA pain; however, it is advised that NSAIDs be used intermittently and not advised for longer periods. NSAIDs can be classified as cyclooxygenase-2 selective agents and nonselective agents [26].
Putative disease-modifying drugs for OA like doxycycline, sprifermin, and cindunistat have not proved significant improvements of the joint so far although the clinical trials conducted to prove the effect of these drugs are still under trial [18].
Bone-forming agents or antiresorptive agents like zoledronic acid, risedronate, strontium ranelate, calcitonin, and vitamin D are classified as bone-acting agents for the management of OA. They are bone-acting agents that showed some recorded effect in the turnover of subchondral bone, although these agents did not show a significant improvement in the structure of the joint [26].
Agents for intra-articular injection include HA and corticosteroids like triamcinolone, betamethasone, and methylprednisolone. Intra-articular injection of corticosteroids showed a greater beneficial effect. Furthermore, during follow-up periods of 3 and 6 months, intra-articular injection of HA showed a better therapeutic effect. Intra-articular injection of a combination of HA and corticosteroids showed a moderate beneficial effect on the pathological process of OA. However, for long-term pain control, intra-articular injection of HA did not show a significant improvement [26].
Use of nonpharmacological modalities (e.g. exercise) as a first-line management for knee OA is little to be compared with pharmacological modalities and usually associated with higher rates of surgical interventions. The results indicate that nonpharmacological agents such as exercise and weight reduction are effective in management of knee OA with minimal adverse side effects. Therefore, exercise and weight reduction should be advised as part of the treatment in most patients owing to their minimal side effects and cost effectiveness, as well as associated health benefits. It is important to specify resources and invest in supporting general practitioners and other primary health care providers to provide lifestyle interventions as a tool in managing knee OA [27].
Irrespective of a large body of evidence concerning the benefits of their use, opiates are used to manage pain associated with Knee OA. No studies fulfilled the inclusion criteria as the follow-up periods of these studies concerning safety were less than 6 months. A recent systematic review of chronic pain management found that there is insufficient evidence to support the effectiveness of long-term opioid therapy [28]. Opioids provide effective analgesia; however, benefits are usually encountered by frequent side effects such as nausea (30%), dizziness (20%), vomiting (13%), constipation (23%), and somnolence (18%) as well as the risk of addiction increases on chronic opioid use. The evidence on the safety and effectiveness of long-term opioid therapy for Knee OA cannot be evaluated. This is a concern and a limitation of the available evidence related to management of Knee OA. In the USA, there has been a significant increase in opioid prescriptions for patients suffering from knee OA, and opioids were prescribed to 15.9% of patients with knee OA [29].
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The historical database is also useful for assisting doctors to support the medical diagnosis. The continuous technological advancements notably, as regards, networking, sensors, and embedded devices have made it possible to monitor and provide assistance to people in their homes. Smart objects with great capabilities for sensing and connecting could revolutionize the way we are monitoring our environment. This chapter consists of a general overview of several real-time monitoring systems developed and published by the authors. 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With particular reference to Nigeria, studies have shown that many urban centres have been experiencing rapid and continuous growth over the years, as people tend to migrate from rural areas to urban centres in order to better their living conditions. However, there has been an inadequacy of the necessary infrastructures to meet the needs of the increasing urban populace. Empirical studies have also shown that about 75% of the urban settlers live in slums and improper housing, which is antithetical to human dignity. Therefore, this study aims at exploring the causes, advantages, and disadvantages of urban slum dwelling in Nigeria, and similarly proper possible solutions to the prevailing urbanization challenges in the country. The authors agree that the policy can bring about an effective provision of affordable housing, thereby meeting the needs of housing and helping to solve most of the problems of urbanization in Nigeria. It is recommended that each element of an effective housing policy, as entrenched in the National Housing Policy 2012, should be critically explored towards the delivery of affordable housing, which would in turn go a long way in solving urbanization problems in Nigeria.",book:{id:"7205",slug:"housing",title:"Housing",fullTitle:"Housing"},signatures:"Temi Oni-Jimoh and Champika Liyanage",authors:[{id:"245547",title:"Mrs.",name:"Temi",middleName:null,surname:"Oni-Jimoh",slug:"temi-oni-jimoh",fullName:"Temi Oni-Jimoh"},{id:"245550",title:"Dr.",name:"Champika",middleName:null,surname:"Liyanage",slug:"champika-liyanage",fullName:"Champika Liyanage"}]},{id:"9627",doi:"10.5772/8410",title:"Aging in Place: Self-Care in Smart Home Environments",slug:"aging-in-place-self-care-in-smart-home-environments",totalDownloads:3363,totalCrossrefCites:9,totalDimensionsCites:10,abstract:null,book:{id:"3631",slug:"smart-home-systems",title:"Smart Home Systems",fullTitle:"Smart Home Systems"},signatures:"Blanson Henkemans, Olivier A., Alpay, Laurence, L., and Dumay Adrie, C.M.",authors:null}],mostDownloadedChaptersLast30Days:[{id:"67068",title:"Structural Design of a Typical American Wood-Framed Single-Family Home",slug:"structural-design-of-a-typical-american-wood-framed-single-family-home",totalDownloads:2508,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Light-wood framing construction techniques have been traditionally used in America for the construction of single-family residences. Dimensional wood lumber is readily available and due to its convenient unit dimension can be packaged neatly and transported to work sites by either commercial transport or personal vehicle. The unit pieces of dimensional lumber are light and easily handled once on the work site. Design of light-framed single-family homes is typically conducted by an architect or construction contractor using prescriptive building codes. A structural engineer can assist, if needed, with design items not within the scope of the building code or if alternative design approaches are required. An owner may choose to involve the engineer to improve quality or economy of the home design. Engineers typically become involved with design items such as foundation design, steel framing design, or engineered product specification. In this chapter, the design of a typical light-framed home is discussed. The main structural assemblies are described and subsequently designed using a combination of prescriptive guidance and engineering design.",book:{id:"8299",slug:"timber-buildings-and-sustainability",title:"Timber Buildings and Sustainability",fullTitle:"Timber Buildings and Sustainability"},signatures:"Anthony C. Jellen and Ali M. Memari",authors:[{id:"252670",title:"Dr.",name:"Ali",middleName:null,surname:"M. Memari",slug:"ali-m.-memari",fullName:"Ali M. Memari"},{id:"276003",title:"Mr.",name:"Anthony",middleName:null,surname:"Jellen",slug:"anthony-jellen",fullName:"Anthony Jellen"}]},{id:"60236",title:"The Feasibility of Constructing Super-Long-Span Bridges with New Materials in 2050",slug:"the-feasibility-of-constructing-super-long-span-bridges-with-new-materials-in-2050",totalDownloads:1824,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"This chapter explores the possibility of designing and constructing a super-long-span bridge with new materials in 2050. The proposed bridge design has a total span of 4440 m with two 330-m end spans and a central span of 3780 m. The height of the two pylons is 702 m, and the deck width is 40 m. The features of this structure include the combination of a suspension bridge and cable-stayed bridge, application of carbon fibre materials, extension of deck width and pretension techniques. Linear static analysis, dynamic analysis and theoretical analysis are conducted under different loading cases. In linear static analysis, the stresses under critical load combinations are smaller than the ultimate strength of the materials. However, the maximum deflection under the dead and wind load combination exceeds the specified serviceability limit.",book:{id:"6395",slug:"bridge-engineering",title:"Bridge Engineering",fullTitle:"Bridge Engineering"},signatures:"Faham Tahmasebinia, Samad Mohammad Ebrahimzadeh\nSepasgozar, Hannah Blum, Kakarla Raghava Reddy, Fernando\nAlonso-Marroquin, Qile Gao, Yang Hu, Xu Wang and Zhongzheng\nWang",authors:[{id:"211659",title:"Dr.",name:"Faham",middleName:null,surname:"Tahmasebinia",slug:"faham-tahmasebinia",fullName:"Faham Tahmasebinia"},{id:"221172",title:"Dr.",name:"Samad M.E.",middleName:null,surname:"Sepasgozar",slug:"samad-m.e.-sepasgozar",fullName:"Samad M.E. Sepasgozar"}]},{id:"61896",title:"Children’s Playgrounds in Slovak Mass Housing Estates: History and Current Trends",slug:"children-s-playgrounds-in-slovak-mass-housing-estates-history-and-current-trends",totalDownloads:1303,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Children’s playgrounds represent an important amenity in the concepts of mass housing, The study chapter presents the unique concepts of children’s playgrounds that have been applied in the Slovak mass housing estates of the second half of the twentieth century, designed by architects and artist, and inspired by the best European experiences, for example, by the landscape design of the Stockholm School. The early inhabitants of the Slovak mass housing estates were predominantly young families with children. The residential aging of this homogenous social structure caused that during the lifespan of housing estates, the demand for playgrounds decreased, they became underused and fell into decay. Today, the social structure of mass housing estates becomes more heterogeneous, what puts new requirements on the design of open public spaces and, as well as, on the regeneration and design of children’s playgrounds, to serve the rising demands of the inhabitants and to enhance the livability of the housing estates. The study examines the current examples of the children’s playgrounds from Slovak mass housing estates, which show that nowadays the typified design of the standardized catalog type elements is used and preferred.",book:{id:"7205",slug:"housing",title:"Housing",fullTitle:"Housing"},signatures:"Katarína Kristiánová",authors:[{id:"224853",title:"Dr.",name:"Katarina",middleName:null,surname:"Kristianova",slug:"katarina-kristianova",fullName:"Katarina Kristianova"}]},{id:"62555",title:"Risk Management in Indonesia Construction Project: A Case Study of a Toll Road Project",slug:"risk-management-in-indonesia-construction-project-a-case-study-of-a-toll-road-project",totalDownloads:2854,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"While project risks are generally acknowledged merely from owner and contractor perspectives, other parties also play important roles in the project. The aim of this study is to analyze the application of risk management in the toll road project from stakeholders’ perception, such as contractor, owner, design consultant, supervisory consultant, and community surrounding the project. Data of risk factors were collected through interviews with each stakeholder, including the probability of occurrence and their impacts. Risk Breakdown Structure (RBS) has been adapted to breakdown project risks from various stakeholders. Risk level of each risk factor is obtained by multiplying the probability and the impact. The overall results of risk analysis show various risks as perceived by each stakeholder due to different roles and interests in the project. This research provides an understanding of how project risks need to be fully comprehended for the success of the project.",book:{id:"5422",slug:"risk-management-treatise-for-engineering-practitioners",title:"Risk Management Treatise for Engineering Practitioners",fullTitle:"Risk Management Treatise for Engineering Practitioners"},signatures:"Mochammad Agung Wibowo, Jati Utomo Dwi Hatmoko and Asri\nNurdiana",authors:[{id:"190479",title:"Dr.",name:"Mochamad Agung",middleName:null,surname:"Wibowo",slug:"mochamad-agung-wibowo",fullName:"Mochamad Agung Wibowo"},{id:"223348",title:"Dr.",name:"Jati",middleName:null,surname:"Dwi Hatmoko",slug:"jati-dwi-hatmoko",fullName:"Jati Dwi Hatmoko"},{id:"223349",title:"MSc.",name:"Asri",middleName:null,surname:"Nurdiana",slug:"asri-nurdiana",fullName:"Asri Nurdiana"}]},{id:"64153",title:"Leadership Initiatives for Health and Safety Risk Management Systems in a Small Construction Company: A Case Study",slug:"leadership-initiatives-for-health-and-safety-risk-management-systems-in-a-small-construction-company",totalDownloads:1475,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The need for leadership in the construction industry has been greater due to the fact that health and safety has become an important business tool to reduce accidents to save lives and minimise injuries. This chapter demonstrates the importance and role of leadership for manging risks associated with health and safety aspects in small construction companies. A case study of an Italian family run small construction company is investigated and reported. A diagnostic tool Leadership and Worker Involvement toolkit was administrated in the company. The toolkit had assessment levels (walking, running and sprinting). Analysis showed the company was at walking and running stages in various aspects. But the leadership aspiration of the company was to reach the ?sprinting? stage as a long-term target and sustain it to minimise health and safety risk. A holistic approach was developed to achieve the leadership aspirations of the company. In conclusion, the role of leadership in small companies is to understand the importance of H&S aspects and develop strategies which are then embedded in the processes of the companies to minimise H&S risks for their sustainability and competitiveness. This chapter is beneficial for professional at site, project and programme level and for leadership team.",book:{id:"5422",slug:"risk-management-treatise-for-engineering-practitioners",title:"Risk Management Treatise for Engineering Practitioners",fullTitle:"Risk Management Treatise for Engineering Practitioners"},signatures:"Subashini Suresh, Chike Oduoza and Suresh Renukappa",authors:[{id:"5932",title:"Dr.",name:"Chike",middleName:null,surname:"Oduoza",slug:"chike-oduoza",fullName:"Chike Oduoza"},{id:"196498",title:"Dr.",name:"Subashini",middleName:null,surname:"Suresh",slug:"subashini-suresh",fullName:"Subashini Suresh"},{id:"207976",title:"Dr.",name:"Suresh",middleName:null,surname:"Renukappa",slug:"suresh-renukappa",fullName:"Suresh Renukappa"}]}],onlineFirstChaptersFilter:{topicId:"705",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:287,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:10,numberOfPublishedChapters:103,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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Completed the Course Medical Mycology, the Centraalbureau voor Schimmelcultures (CBS), Fungal Biodiversity Centre, Netherlands (2006). International Union of Microbiological Societies (IUMS) Fellow, and International Emerging Infectious Diseases (IEID) Fellow, Centers for Diseases Control and Prevention (CDC), Atlanta, USA. Diploma of Dermatological Scientist, Japanese Society for Investigative Dermatology. Ph.D. of Juntendo University, Japan. Bachelor’s and Master’s degree, Medicine, West China University of Medical Sciences. Chair of Sichuan Medical Association Dermatology Committee. General Secretary of The 19th Annual Meeting of Chinese Society of Dermatology and the Asia Pacific Society for Medical Mycology (2013). In charge of the Annual Medical Mycology Course over 20-years authorized by National Continue Medical Education Committee of China. Member of the board of directors of the Asia-Pacific Society for Medical Mycology (APSMM). Associate editor of Mycopathologia. Vice-chief of the editorial board of Chinses Journal of Mycology, China. Board Member and Chair of Mycology Group of Chinese Society of Dermatology.",institutionString:null,institution:{name:"Sichuan University",institutionURL:null,country:{name:"China"}}},editorTwo:null,editorThree:null},{id:"5",title:"Parasitic Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/5.jpg",isOpenForSubmission:!0,editor:{id:"67907",title:"Dr.",name:"Amidou",middleName:null,surname:"Samie",slug:"amidou-samie",fullName:"Amidou Samie",profilePictureURL:"https://mts.intechopen.com/storage/users/67907/images/system/67907.jpg",biography:"Dr. Amidou Samie is an Associate Professor of Microbiology at the University of Venda, in South Africa, where he graduated for his PhD in May 2008. He joined the Department of Microbiology the same year and has been giving lectures on topics covering parasitology, immunology, molecular biology and industrial microbiology. He is currently a rated researcher by the National Research Foundation of South Africa at category C2. He has published widely in the field of infectious diseases and has overseen several MSc’s and PhDs. His research activities mostly cover topics on infectious diseases from epidemiology to control. His particular interest lies in the study of intestinal protozoan parasites and opportunistic infections among HIV patients as well as the potential impact of childhood diarrhoea on growth and child development. He also conducts research on water-borne diseases and water quality and is involved in the evaluation of point-of-use water treatment technologies using silver and copper nanoparticles in collaboration with the University of Virginia, USA. 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His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. 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He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. 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