Osteoarthritis (OA) is a condition that I see on a daily basis in practice. Although it is extremely common, there are many misconceptions out there regarding symptom management. Hopefully after reading this blog you feel educated, empowered and on the right track to managing your osteoarthritis.
I recently completed an online course on knee OA through University of Melbourne called PEAK, which has helped me fine tune my treatment approach and increase the positive impact I can have for patients with this condition. I would highly recommend this course to other practitioners to help understand this topic and put together an effective treatment process.
What is OA:
Taken from the National Clinical Guideline Centre (NICE, 2014) “Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life. It is the most common form of arthritis, and one of the leading causes of pain and disability worldwide. The most commonly affected peripheral joints are the knees, hips and small hand joints.
Contrary to popular belief, OA is not caused by ageing and does not necessarily deteriorate. There are a number of management and treatment options (both pharmacological and non-pharmacological), which this guideline addresses and which offer effective interventions for control of symptoms and improving function.”
Pain & Progression of OA
Pain is probably the most common symptom identified by patients presenting with OA. Pain is generally thought to be related to structural changes or injuries but we now know this is not always the case. Pain is a complex biopsychosocial issue, related in part to a person’s expectations and self-efficacy (sense of one’s own ability to accomplish a task), and associated with changes in mood, sleep and coping abilities. Due to this complexity, there is often a poor link between changes on an X-ray and pain symptoms: minor changes can be associated with a lot of pain and bigger changes to joints often can occur with minimal accompanying pain.
Major risk factors for worsening of pain and/or physical function include:
- Increasing age
- Increasing body mass index
- Increased co-morbidity count
- Higher baseline severity (both radiographic and symptomatic)
- Depressive symptoms
- Muscle weakness
- Slower walking speed
There is strong evidence that sex, former injury, specific muscular weakness, smoking, running and regular performance of sports are not associated with OA structural progression.
OA and General Health
The prevalence of comorbidities among patients with OA is high. Common comorbidities include:
- High blood pressure
- Diabetes
- Cardiovascular disease
- Depression and anxiety
- Obesity
- Chronic obstructive pulmonary disease
In Australia, according to the ABS National Health Survey (2014–15), among people with OA:
- 51% reported also having cardiovascular disease compared with 15% of people without OA
- 35% reported also having back problems compared with 14% of people without OA
- 18% reported also having mental health problems compared with 11% of people without OA.
Assessment of OA:
The below picture to help sum up the information that is required for a thorough holistic assessment of a patient with OA. All of these different factors can play a role in the pain that you are experiencing and how an appropriate treatment plan should be implemented for you.
After gathering the information required needed from the above image. A movement assessment would be performed to assess how you move, typically this would involve a gait assessment and other task specific patterns/movements that are relevant to you. Further to this, assessment should involve obtaining some objective measures. These objective measures allow us to understand your current capacity and track improvements through the treatment plan.
Treatment for OA
Education:
Education should be a mainstay of the whole treatment plan, from initial assessment to discharge from treatment. Initially, education would be based around understanding what osteoarthritis is and is not. We decide collaboratively which aspects/issues are contributing the most to your presentation and put specific plans in place to address them. As discussed in the assessment component of this blog that could be anything such as activity, sleep, thoughts about a particular topic and support networks.
The way in which we communicate or the language that we use for this education is paramount. Positive communication behaviour plays a role in getting the best outcomes for patients, this includes:
- Body language
- Active Listening
- Empathy / Care
- Eye contact
- Using positive wording as opposed to negative wording
- Celebrating success as opposed to focusing on mistakes
- Educating as opposed to criticizing or punishing
- Portraying confidence as opposed to fear
Physical Activity:
Physical activity can include a number of different types of activity. A conversation between practitioner and patient should be had to help understand what the patient enjoys doing, what they can commit to. Some examples of activity that would be a part of a plan for OA patients include walking, strengthening programs that are either supervised or home programs, hydrotherapy, balance or proprioceptive work and specific task a patient enjoys. This could be anything from Tai Chi to ballroom dancing to running. Ideally a combination of all of these types of activity will be used.
Most research looking at the use of exercise and physical activity in OA is focused on knee. For knee OA exercise has been shown to:
- Reduced pain (short term and longer term)
- Decrease disability
- Decrease medication intake
- improved physical functioning such as stair climbing & walking distance
- Increase muscle strength
- Improve balance
- Improve patient self-efficacy
- Improve patient’s mental health
More research needs to be conducted to understand the benefit of this for other joints effected by osteoarthritis.
Weight loss:
Arukorala and colleagues (2016) established a dose‐related symptomatic response to weight reduction in people with knee OA in a community setting. It also demonstrates that a clinically relevant improvement in symptoms can be achieved with a relatively modest weight loss. The research shows that 10% weight loss resulted in less pain, better function, improved health‐related quality of life, reduced knee joint loads, and less inflammation compared with no weight loss or <10% weight loss. Therefore, for clients who are either classed as overweight or obese a plan should be put in place to help patients try to achieve this 10% loss in body weight. A referral to a dietitian can be helpful in getting the client to achieve this.
Supplements:
There is not a great deal of quality research on the benefits of supplements for OA. Those commonly promoted to benefit OA are glucosamine, chondroitin or a combination of these two. However, within the current body of literature, these two, as well as Vitamin D, have so far demonstrated to have no effect on OA. But there is hope.
A recent 2019 study compared the efficacy and safety of curcumin with those of diclofenac (which is a non-steroidal anti-inflammatory drugs) in the treatment of knee OA. They found:
- At days 14 and 28, patients receiving curcumin showed similar improvement in severity of pain
- At day 7, the patients who received curcumin experienced a significantly greater reduction in the number of episodes of flatulence compared with diclofenac
- At day 28, a weight-lowering effect and anti-ulcer effect of curcumin were observed. None of the patients required H2 blockers in the curcumin group, and 19 patients required H2 blockers in the diclofenac group
- Adverse effects were significantly less in the curcumin group 13% versus 38% in the diclofenac group
Although there is still more research that needs to be completed in this area. It shows that curcumin can be an alternative treatment option in the patients with knee OA who are intolerant to the side effects of non-steroidal anti-inflammatory drugs like diclofenac.
Summary & What to do:
The pain and disability that can result from OA is not something that you just have to accept until you get a joint replacement. There are many things to help manage your pain levels and improve your functionality that are within your control. Some of the main misconceptions to remember about OA are:
- Pain comes from the wearing down of the cartilage
- OA always gets worse overtime
- Exercise will make OA worse
- There is nothing that can be done to help
- Joint replacement surgery is always needed
People with symptomatic osteoarthritis should find a practitioner that values and implements:
- Assessment – looking at the effect of OA on your function, quality of life, occupation, mood, relationships and leisure activities
- Education – helping you understand what is going on and how we structure a plan to address these issues
- Communication – the language that a practitioner should use is non threating (avoid using misleading terms like bone on bone, wearing down of cartilage, progressive degeneration etc.), positive and reassuring in nature
- Physical activity – some form of exercise should be incorporated in your treatment plan; this should be based around your current activity levels and your future goals. It should be progressive in nature continue to upon getting you closer to reaching those goals
- Weight loss strategies – if you are overweight or obese then making small and sustainable changes to help this will be needed, with the potential referral to a dietitian to help this
If you would like to understand how our team at Absolute Health & Performance can help you manage you pain from Osteoarthritis and get you achieving your goals, feel free to email on [email protected]
Written By Osteopath Ashley Gudgeon
References:
- National Clinical Guideline Centre (NICE). (2014). Osteoarthritis: care and management in adults. NICE clinical guideline 177.
- University of Melbourne – PEAK Training Program – Knee OA Course (2020)
- Royal Australian College of General Practitioners. (2018). Guideline for the Management of Knee and Hip Osteoarthritis.
- Bannuru, R. R., Osani, M. C., Vaysbrot, E. E., Arden, N. K., Bennell, K., Bierma-Zeinstra, S. M. A., … & Blanco, F. J. (2019). OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and cartilage, 27(11), 1578-1589.
- Bastick AN, Belo JN, Runhaar J, Bierma-Zeinstra SM. What Are the Prognostic Factors for Radiographic Progression of Knee Osteoarthritis? A Meta-analysis. Clin Orthop Relat Res. Sep 2015;473(9):2969-2989.
- Bastick AN, Runhaar J, Belo JN, Bierma-Zeinstra SM. Prognostic factors for progression of clinical osteoarthritis of the knee: a systematic review of observational studies. Arthritis Res Ther. Jun 8 2015;17:152
- Atukorala, I., Makovey, J., Lawler, L., Messier, S. P., Bennell, K., & Hunter, D. J. (2016). Is there a dose‐response relationship between weight loss and symptom improvement in persons with knee osteoarthritis?. Arthritis care & research, 68(8), 1106-1114.
- Makovey, J., Lawler, L., Bennell, K. L., & Hunter, D. J. (2015). Dose response relationship between weight loss and improvement in quality of life in persons with symptomatic knee osteoarthritis. Osteoarthritis and Cartilage, 23, A386.
- Messier, S. P., Gutekunst, D. J., Davis, C., & DeVita, P. (2005). Weight loss reduces knee‐joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis & Rheumatism, 52(7), 2026-2032.
- Bliddal, H., Leeds, A. R., & Christensen, R. (2014). Osteoarthritis, obesity and weight loss: evidence, hypotheses and horizons–a scoping review. Obesity reviews, 15(7), 578-586.
- Shep, D., Khanwelkar, C., Gade, P., & Karad, S. (2019). Safety and efficacy of curcumin versus diclofenac in knee osteoarthritis: a randomized open-label parallel-arm study. Trials, 20(1), 214.
- Arden, N. K., Cro, S., Sheard, S., Doré, C. J., Bara, A., Tebbs, S. A., … & Macgregor, A. (2016). The effect of vitamin D supplementation on knee osteoarthritis, the VIDEO study: a randomised controlled trial. Osteoarthritis and cartilage, 24(11), 1858-1866.
- Peluso, R., Caso, F., Costa, L., Sorbo, D., Carraturo, N., Di, M. M., … & Scarpa, R. (2016). Mud-bath therapy and oral glucosamine sulfate in patients with knee osteoarthritis: a randomized, controlled, crossover study. Clinical and experimental rheumatology, 34(4), 618-624.
- Tsuji, T., Yoon, J., Kitano, N., Okura, T., & Tanaka, K. (2016). Effects of N-acetyl glucosamine and chondroitin sulfate supplementation on knee pain and self-reported knee function in middle-aged and older Japanese adults: a randomized, double-blind, placebo-controlled trial. Aging clinical and experimental research, 28(2), 197-205.
- Messier SP, Loeser RF, Miller GD, et al. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum 2004; 50: 1501–10. 81
- Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA 2013; 310: 1263–73
- Messier, S. P., Resnik, A. E., Beavers, D. P., Mihalko, S. L., Miller, G. D., Nicklas, B. J., … & Guermazi, A. (2018). Intentional weight loss in overweight and obese patients with knee osteoarthritis: is more better?. Arthritis care & research, 70(11), 1569-1575.
- Atukorala, I., Makovey, J., Lawler, L., Messier, S. P., Bennell, K., & Hunter, D. J. (2016). Is there a dose‐response relationship between weight loss and symptom improvement in persons with knee osteoarthritis?. Arthritis care & research, 68(8), 1106-1114.
- Cover Image Source: https://www.newswise.com/articles/the-medical-minute-seven-surprising-facts-about-osteoarthritis
