Do We Need to Rethink Osteoarthritis?

Martin Basedow and his research team out of the University of South Australia report that the recommendations and treatments patients receive for osteoarthritis are often variable and divergent from the guidelines. (1)

Osteoarthritis Guidelines Versus the Common Scenario

Broadly speaking, clinical guidelines recommend therapeutic exercise and weight loss as first-line treatments for knee and hip osteoarthritis. Second-line treatments include self-management support, education, and finally non-steroidal anti-inflammatory drugs. In short, most patients with rehab potential should be receiving referrals to physiotherapy. If all of this together doesn’t manage the osteoarthritis effectively enough, it’s time for a joint replacement surgery – which comes with even more therapeutic exercise. People have a strong tendency to skip the physiotherapy while not seeking exercise physiologist guidance for weight loss and self-management strategies. Instead, they read a couple pages of a help sheet, go straight to drugs, and then surgery. 

The Myth That Osteoarthritis is a Natural Consequence of Aging

University of Melbourne’s Thorlene Egerton set out to discover why people are not receiving guideline-consistent osteoarthritis care. (2) Egerton and colleagues performed a systematic review and synthesis of previously published surveys of general practitioners, physiotherapists, practice nurses, etc. They were asked about prevailing dispositions toward osteoarthritis.

One of the themes that emerged was the idea that osteoarthritis is not a disease, is not serious, and therefore is not something that should really be treated. The idea expressed was that osteoarthritis is simply a normal consequence of aging and part of the life process. Fortunately, this is a misconception.

In truth, only a minority of people have osteoarthritis. While osteoarthritis grows more common as we age, even among the elderly, only a minority have it. (3) It is avoidable. Furthermore, osteoarthritis causes more disability in walking, stair climbing, and housekeeping than any other disease. (4) It is serious.

Osteoarthritis Is Treatable and Reversible

Another theme to emerge from Egerton’s research is the misconception that there is nothing that can be done about osteoarthritis. Egerton and colleagues theorize that this stems from inadequate treatment approaches. Patients receive a sheet of exercises and advice to lose weight. A year later, they weigh the same and they found the exercises ineffective. Resultantly, people form the opinion that exercise and diet don’t work.

While it is true that the approach described above doesn’t work, research shows that medium to high-intensity counselling does achieve medium to large lifestyle changes – especially where diet is concerned. The most successful interventions involve multiple training and counselling sessions spread over weeks or even months. Fortunately, this schedule completely fits the normal practice model of physiotherapy and exercise physiology, and that team is a natural fit for that sort of planning, advice, and counselling.  Furthermore, and perhaps most importantly, when physiotherapists provide the therapeutic exercise treatments as part of the first-line approach to osteoarthritis, patients get better and healthcare spending goes down. Success is not 100%, but, on average, patients who receive physiotherapy for osteoarthritis get better. In fact, physiotherapy reverses the progression of osteoarthritis for years. (5)[MK1] 

 

References:

1. Basedow M, Williams H, Shanahan EM, Runciman WB, Esterman A. Australian GP management of osteoarthritis following the release of the RACGP guideline for the non-surgical management of hip and knee osteoarthritis. BMC Research Notes. 2015 Dec; 8 (1): 536. 
2. Egerton T, Diamond LE, Buchbinder R, Bennell KL, Slade SC. A systematic review and evidence synthesis of qualitative studies to identify primary care clinicians' barriers and enablers to the management of osteoarthritis. Osteoarthritis and Cartilage. 2017 May 1; 25 (5): 625-38.
3. Englund M, Turkiewicz A. Osteoarthritis increasingly common public disease. Lakartidningen. 2014; 111 (21): 930.
4. van Dijk G, Dekker J, Vennhof C, et al. Course of functional status and pain in osteoarthritis of the hip or knee: a systematic review of the literature. Arthritis Rheum. 2006; 55: 779-85.
5. Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. Journal of Orthopaedic Trauma. 2006 Nov 1; 20(10): 739-44.