What is Osteoarthritis:
Osteoarthritis is the most common form of arthritis and is one of the leading causes of pain and disability. It referrers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and subsequent reduced quality of life.
Pain, reduced function and effects on a person’s ability to carry out their day-to day activities can be important consequences of osteoarthritis. This can lead to changes in a patients mood, sleep and coping abilities. There is often a poor link between changes visible on an x-ray and symptoms of osteoarthritis ; minimal changes can be associated with a lot of pain, or modest structural changes to joints can occur with minimal accompanying symptoms. Contrary to popular belief, osteoarthritis is not linked to ageing and does not necessarily deteriorate. There are a number of management and treatment options (both pharmological and non- pharmalogical) which we will cover.
Osteoarthritis is a condition that results from a loss of cartilage with subsequent remodelling of adjacent bone and subsequent inflammation. It is some of these changes in the joint structure that can then be seen on x-ray.
It is a dynamic process that involves all joint tissues: the bones, cartilage, joint capsule, lubricating fluid and surrounding muscles.
Sometimes the altered joint structure compensates for the changes and does not cause pain. It’s when the natural repair process cannot compensate enough that the joint starts to become painful.
The exact cause of the pain is not well understood, but it can come from the soft tissue as well as the joint. As mentioned, what we see on x-ray does not closely match how people feel or what they can do. This is due to the effect of peoples thought and beliefs and how and what they do. For example, people with osteaoarthritis who are frightened to move and limit their activity suffer more pain and disability.
However, it is important to note that osteoarthritis is a dynamic process with the potential for some repair – especially with the right advise and guidance. This means staying mobile, strengthening the muscles around the joint and weight management .
What causes osteoarthritis:
There is not thought to be one single cause of osteoarthritis , but various things are thought to be involved:
- Genetic Factors – Can run in families and some types are more common in certain ethnic groups
- People who are overweight are at a higher risk
- It is more common in women than men
- Various physical factors may play a part, but they do not have a consistent effect ; previous damage to the joint surface , some physically intense occupations and sports , reduced muscle strength, abnormal joint shape or alignment.
- Age – painful osteoarthritis is uncommon in younger people
Important points to note:
- The pain of osteoarthritis does not always get worse. Quite a few people see improvement
- It should not stop someone staying active and getting on with their life as normal
- Having Osteoarthritis does not mean that people need to stop work – many people with painful osteoarthritis remain in work
- Not everyone with osteoarthritis will need surgery
Osteoarthritis can be diagnosed clinically without further investigations if a person is:
- 45 and over and
- Has activity related joint pain and
- Has either no morning joint –related stiffness or morning stiffness that lasts fewer than 30 minutes.
Be aware that atypical features , such as a history of trauma, prolonged morning joint related stiffness , rapid worsening of symptoms or a hot swollen joint may indicate alternative or additional diagnosis. Important differential diagnosis include gout, other inflammatory arthritis (e.g. rheumatoid arthritis), septic arthritis and malignancy (bone pain).
It is important for patients to be aware that their symptoms may fluctuate from day to day. Most people find they get flare ups from time to time with or without a trigger. It may be that activities need to be modified for a while, but it will settle down and usual activities can be resumed. It is not a sign that the condition is getting worse.
Managing Osteoarthritis :
As with many conditions affecting older people, there is no complete cure for osteoarthritis, but the problem can be managed and controlled.
Education & Self Management :
Offer accurate written and verbal information to all people with osteoarthritis to enhance understanding and counter misconceptions, such as that it will inevitably progress and cannot be treated.
Patient self management interventions:
Agree individualised self management strategies for a person with osteoarthritis. Ensure positive behavioural changes such as exercise, weight loss, use of appropriate footwear and pacing.
It is important that self management programmes for people with osteoarthritis , either individually or in groups emphasise the recommended core treatments – Education, advice, access to information, exercises (muscle strength and aerobic training) , weight loss if overweight or obese.
Non- Pharmalogical Management :
Advise people with osteoarthritis to exercise as a core treatment (NICE Guidance CG 177)irrespective of age , comorbidity , pain severity or disability. Exercises should include:
- local muscle training
- general aerobic training
Regular physical activity or exercise:
- Strengthens and stretches muscles around the joint
- Maintains flexibility by getting the stiff joint to move
- Helps increase bone density
- Challenges the heart and lungs to increase fitness
- Releases natural chemicals that reduce pain and improve mood
- Gives the patient control of their symptoms
These are some of the reasons that exercise remains one of the core treatments for osteoarthritis.
High impact sports are best avoided but pretty much anything else is fine:
- Cycling/exercise bike
- Swimming and aquarobics
- Gym workouts
- Golf or bowls
- Tai chi, yoya , pilates , dance
It is important that some form of exercise is performed daily. Pain killers can be used to control the pain before initiating any form of exercise.
- Weight loss interventions should be offered as a core treatment to anyone who is overweight or obese ( NICE Guidance CG177).
- Most people will notice an improvement in joint pain and function after losing 5% of their body weight
- The average person might need to lose 3-4kg (6-8lb) to notice a difference.
- Clinicians should consider the use of Trascutaneous Electrical Nerve Stimulation (TENS) as an adjunct to treatment for pain control
- These machines are relatively inexpensive and can be purchased from most chemists or online
- The use of heat and cold should be used as an adjunct to therapy (NICE Guidance CG 177)
- This can be particularly useful for flare ups of pain
- The use of a cold pack on the joint for 5-10 minutes (a bag of frozen peas wrapped in damp tea towel) may help alleviate symptoms in the short term
- Other people prefer heat and hot packs can be purchased from most pharmacies, or use a hot water bottle, warm shower or bath.
Aids & Devices:
- Offer advice on appropriate footwear ( including the use of supportive shoes with good shock absorbing properties) as part of the core treatment (NICE Guidance GG177).
- People with osteoarthritis who have biomechanical joint pain or instability should be considered for assessment for bracing, joint supports, insoles as an adjunct to their core treatment.
- Many people will not require walking aids but for more severe cases a physiotherapists can advise on the use of walking sticks and other walking aids as required
Pharmacological Management :
- Healthcare professionals should consider offering paracetamol for pain relief in addition to core treatment and regular dosing may be required.
- Paracetamol and/or topical non steroidal anti-inflammatory drugs (NSAIDS) should be consider ahead of oral NSAIDS, cyclo-oxygenase 2 (COX-2 ) inhibitors or opiods. (NICE Guidance CG 177)
- If paracetamol or NSAIDS are insufficient pain relief for people with osteoarthritis, then the addition of opiod analgesics should be considered .Risks and benefits should be considered particularly in older population
- Consider topical NSAIDS in addition to the core treatments for patients with osteoarthritis of the knee. Consider topical NSAIDS and /or paracetamol ahead of oral NSAIDS, COX-2 inhibitors and opiods
- Topical capsaicin should be considered as an adjunct to core treatment for patients with osteoarthritis of the knee(NICE Guidance CG177)
- Do not offer rubefacients for treating osteoarthritis
NSAIDS and highly selective COX-2 Inhibitors :
- Although NSAIDs and COX-2 inhibitors may be regarded as a sigle drug class of ‘NSAIDS’, these recommendations use the two terms for clarity and because of the differences in side-effect profile.
- Where paracetamol or topical NSAIDs are ineffective for pain relief for people with osteoarthritis , then substitution with an oral NSAID/COX-2 inhibitor to paracetamol should be considered
- Where paracetamol or topical NSAIDs provide insufficient pain relief for people with osteoarthritis , then the addition of an oral NSAID/COX-2 inhibitor to paracetamol should be considered.
- Use oral NSAID’s/COX-2 inhibitors at the lowest effective does for the shortest period of time.
- When offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor (other than etoricoxib 60mg) . In either case , co-prescribe with a proton pump inhibitor (PPI) , choosing the one with the lowest acquisition cost.
- All oral NSAIDs/COX-2 inhibitors have analgesic effects of a similar magnitude but vary in their potential gastrointestinal , liver, cardio-renal toxicity, therefore, when choosing the agent and dose, take into account individual patient risk factors, including age. When prescribing these drugs, consideration should be given to appropriate assessment and /or on-going monitoring of these risk factors
- If a person with osteoarthritis needs to take low-dose aspirin, healthcare professionals should consider other analgesics before substituting or adding an NSAID or COX-2 inhibitor (with a PPI) in pain relief is insufficient or ineffective.
(NICE Guidance CG177)
Referral for consideration of Joint surgery:
- Please refer to the OA Hip pathway
- If you have a patient that you feel requires joint surgery please refer onto the pathway where the physiotherapist will arrange a referral to an orthopaedic surgeon of the patients choice as well as help them in preparation for their forthcoming surgery
- Patients are referred to surgery when their symptoms are having a significant impact on their lifestyle and non- surgical treatments , as suggested, have failed to improve pain and function.
- The physiotherapist can ensure that the patient has a realistic expectation of what to expect from their surgery as well as discussing benefits and risks, what to expect post –surgery , recovery and rehabilitation, to ensure that the patient is able to make and informed decision regarding their care.
- Patient specific factors such as age , sex, smoking, co-morbities and weight are not barriers to onward referral for surgery.