The term osteoarthritis embraces a wide spectrum of clinical conditions with the common feature of primary joint failure. While prevention is the ideal goal, opportunities to achieve it are limited by our incomplete understanding of the aetiopathology. The principles of nonpharmacological management are education about the condition, modification of lifestyle, and judicious exercise and joint protection, together with adequate pain relief. Optimum management involves a team approach which includes orthopaedic surgical expertise, as surgery can provide an alternative to continuing discomfort and limited mobility.
Osteoarthritis (OA) is the most common joint disorder in humans and increases with increasing age. It affects up to 70% of the population over 65 years of age as well as a significant proportion of younger people. Osteoarthritis is multi factorial in causation and may be defined as primary failure of the joint with degeneration of articular cartilage.
The pathophysiology of the condition has been well reviewed.1 Genetic, physical, chemical and possibly immunological factors are involved. The disorder may be primary or the almost inevitable sequel to previous joint damage.
There are 3 broad groups:
i. symmetrical peripheral arthritis
- Heberden's nodes
- primary generalised osteoarthritis (PGOA) in females
- nonnodal OA in males
ii. oligoarticular large joint disease
iii. spinal arthritis
- apophyseal OA While OA is generally accepted as non inflammatory in nature, localised inflammation can be demonstrated and may be prominent in certain forms such as 'erosive OA' of the fingers. However, in most instances, the precise aetiology cannot be defined and changes in articular cartilage are present long before clinical manifestations become apparent.
Osteoarthritis is aggravated by several factors including obesity, occupation, the nature of any previous joint damage and the presence of underlying joint disease. Recognition of these factors provides an opportunity for primary, secondary and tertiary preventive interventions, which include:
- Weight reduction in the case of knees and hips, this is probably the most important factor and even minor reductions of 3-4 kg may make the difference between immobility and preserved weight bearing joint function.
- Occupational modification hip disease is common in farmers, while hand and wrist disease are aggravated by certain occupations such as pneumatic drilling. Back problems are common in labourers and miners. Recreational activities such as knitting and crocheting may aggravate hand and wrist OA. Ideally, these activities should be modified, but unfortunately, this is not always practicable.
- Joint protection recognition of preexisting problems leading to premature OA such as previous injury or preexisting disease, e.g. ligamentous knee damage or underlying inflammatory arthritis, allows instruction in joint protection to minimise damage. Sensible advice may involve selective limitation of activity, the use of resting splints and other orthoses, walking sticks, crutches and wheelchairs.
- Team management the inclusion of physiotherapists and occupational therapists in a program involving muscle strengthening exercises, hydrotherapy, occupational and domestic activities of daily living assessment is a vital component in a comprehensive care program.
- Analgesic techniques relaxation therapy, transcutaneous electrical nerve stimulation (TENS) and acupuncture all have a place.
- Education educational groups for patients and relatives, including 'back schools' and arthritis education programs, teach coping skills and provide group experience.
Six questions should be asked when considering the nonpharmacological management of any patient with OA or a potential sufferer from this disease.
1. Is there a family history of joint disease?
The severe familial forms of OA are rare and perhaps are related to type II collagen gene mutations, but other forms particularly involving hands, spine, hips and knees occur more frequently and advice about joint protection should be offered. Recognition of a familial predisposition allows earlier advice about joint protection, although the disease process continues.
2. What advice should be given to young sports people and workers in high risk occupations?
An awareness of the potential for injury in specific sports needs to be developed e.g. neck and spinal injuries in rugby, and knee injuries (including meniscal and ligamentous damage) in soccer, Australian rules, skiing and cycling. Sports medicine clinics with multidisciplinary staffing have an important role in the management of sporting injuries both initially and during return to competition. Their contribution to the education of sports people at all levels of participation and to the primary and secondary prevention of OA needs to be fostered.
Knee injuries are a major concern as there is little evidence that cruciate ligament repair, while obviously necessary after major trauma, alters the prevalence and rate of progression of subsequent OA. Similarly, the recognition of occupational risks in certain industries needs to be increased and protective strategies introduced in conjunction with expert ergonomic advice and the cooperation of employers.
It is obvious that a third generation farmer with a family history of OA of the hip in parent and grandparent should seriously consider alternative, less physically demanding work. In other occupational situations, ergonomic assessment of the workplace may allow modification of physically stressful environments. Employers are now more likely to accept, or even welcome, such intervention.
3. Is advice about joint protection available and, if so, is it appropriate and practicable?
There is often a conflict between the need for reduced activity and the hazards of subsequent excessive weight gain or diminished exercise reserve. Changes in types of exercise and planned programs should overcome this problem after discussion between the management team members and the patient.
Often advice from well meaning friends is inappropriate and can result in increased stress on affected joints by encouraging excessive use and, consequently, further cartilage damage. Patients with knee OA are frequently surprised to be advised by their doctors to avoid climbing stairs, squatting or excessively using stationary exercise bikes. In addition, the use of weights during active knee exercise, while appropriate for the fit young athlete, may aggravate OA in the knees of older patients.
4. What educational resources are available?
Most metropolitan and base hospitals have physiotherapists and occupational therapists trained in individual and group teaching techniques. Teaching programs are generally based on educational material developed by the Arthritis Foundation of Australia and other self help organisations. Similar advice is also available from allied health professionals in private practice or employed in industry. The development of 'back schools' has been an important advance in this area.2
5. Have physical regimens for pain relief been given a fair trial?
Simple mechanical devices such as a shoe raise for leg length inequality, insoles for shoes and modified footwear can occasionally make a dramatic difference in lower limb and spinal disease. The use of a lumbar support when driving a car or a wrap around corset may relieve chronic back pain. Resting and working splints, the correct use of a walking stick and modification of home facilities all need to be considered.
For the management of the OA of the hands, wax bath therapy or ultrasound in a water bath produces pain relief and allows more effective joint movement and at least temporary improvement in hand function. A modified technique of local moist heat application can be used at home. The hands are liberally covered with baby oil, inserted into thick rubber gloves and then exercised gently in water as hot as can be tolerated for about 10 minutes once or twice daily for pain relief. Any particularly painful small joints may then be rubbed with a suitable liniment or cream. Many preparations contain salicylate or non steroidal anti inflammatory drugs, but there is little evidence of therapeutically effective skin penetration.
Hydrotherapy is clearly perceived by both patients and therapists to be effective, but its efficacy has not been fully researched and evaluated. The warm water induces pain relief and muscle relaxation and, with the reduction of the effect of gravity, allows more effective joint movement and muscle strengthening.
The availability of TENS machines is limited and, when effective, long term use usually requires the purchase of a machine by the patient or a relative. Most physiotherapy departments can arrange a trial period with the machine to assess its efficacy in pain relief. Acupuncture is rarely available in public hospitals outside pain management centres.
Unfortunately, in the present climate of budgetry restraint in most publicly funded services, there can be considerable delay in the provision of services and many patients are unable to afford alternative private facilities.
6. Finally, is surgical treatment the best option?
Procedures such as osteotomy, total joint arthroplasty or arthrodesis may all have a place in certain situations. Total joint replacement has revolutionised the management of degenerative joint disease in the hip and knee joints.
The patient should be reviewed by a rheumatologist if
- the diagnosis of the joint problem is in doubt
- access to ancillary services and hydrotherapy is difficult
- after a period of treatment, the condition is not controlled, or complications are apparent.
There are many approaches to the management of patients with osteoarthritis. Nonpharmacological treatment has an important role in the total care of the patient and is often undervalued and under utilised.
- Brandt KD, Radin E. The physiology of articular stress: osteoarthrosis. Hosp Pract 1987;22:103-7, 110-2, 117.
- Kennedy B. An Australian programme for management of back problems. Physiotherapy 1980;66:108-11.