Osteoarthritis in the Hip and Knee
Osteoarthritis (OA) is a common condition that affects the joints of the body. It is characterised by changes in the joint structures, for example a reduction in cartilage. These changes occur because of complex mechanisms, including inflammatory processes, biomechanics and even genetics. Knee OA in particular affects many Australians – many of us know of someone who has been diagnosed with the condition. It has a high burden on the health care system and is a major contributor to disability and lost productivity.
Recent studies demonstrate that many people living with knee osteoarthritis are unaware of how best to manage their condition. Many people are referred straight to surgery without trying any form of conservative (non-surgical) management. Knee replacement surgery has been growing at an unsustainable rate over the past few decades – in Victoria there has been a 285% increase since the 1990s. Recent evidence has suggested that 25% of knee replacement surgeries are considered not necessary. Another surgical intervention, arthroscopy, has also been on the rise, despite there being high-level evidence of the procedure unlikely to benefit those diagnosed with knee OA. Joint replacement surgery will be indicated for a sub-group of people with advanced joint degeneration and who have exhausted non-surgical care options. This month’s newsletter will discuss non-surgical care options for those diagnosed with knee or hip OA.
Clinically, people presenting with knee osteoarthritis complain of painful and restricted movement about the affected joint. As a result of pain and restricted mobility, patients often have reduced muscle strength in their affected leg. This presentation is enough to clinically diagnose someone as having osteoarthritis – imaging (for example an x-ray) is not always necessary. Also, there is a poor correlation between structural changes visible on imaging and a patient’s clinical symptoms, and it is common for people with no physical symptoms to have evidence of structural changes on imaging. Imaging should therefore be reserved for special cases, for example if needing to exclude other pathology.
To be able to effectively manage your OA, it is important to be aware of the variety of treatment options available. Best practice strongly suggests conservative management should be trialled for at least three months before any surgical intervention is considered. There is strong evidence demonstrating that increasing muscle strength around the knee results in improvements such as a reduction in pain and increased function. Your physiotherapist will be able to provide you with an exercise program tailored to your current ability. Having an adequate understanding of pain mechanisms is very important, as there are many contributors to pain including changes in joint structure, activity, sleep, diet, thoughts and feelings. Pacing your daily activity (not doing too much on your ‘good’ days or too little on your ‘bad’ days) is often a helpful strategy.
There are other management options that should be also be considered when developing a management plan for your knee OA. Weight loss, if indicated, is important to reduce the amount of load going through the knee joint. The use of basic medication (for example paracetamol and anti-inflammatories) to assist in managing pain can also be useful. Using pain medication should always be in conjunction with other form of management and never the sole treatment option. Osteoarthritis is generally managed best with a combination of these different strategies.
We are all living longer, it’s a myth you should just put up with your pain as you get older. Best practice care for knee or hip OA is provision of appropriate non-surgical care. At Central Bassendean Physiotherapy we ensure our Physiotherapists understand OA and the related pain. We will formulate a targeted and individualised strategy based on contemporary best evidence to manage symptoms and improve functioning.
Curtin University 2013
Jezamine has a keen interest in managing chronic conditions, particularly low back pain, and non-musculoskeletal conditions such as COPD. She also enjoys assisting in rehabilitation of sports people following an injury. In addition to treating at the clinic, Jezamine also runs the Thursday afternoon Hydrotherapy sessions at Bayswater Waves, as well as Clinical Pilates classes twice per week on Monday and Wednesday afternoons.
When not at work, Jezamine likes to keep active by playing netball for North Dianella Netball Club and getting out and about with her fur-baby, Henry.
Low Back Pain (LBP) and Cognitive Functional Therapy (CFT)
WHAT IS COGNITIVE FUNCTIONAL THERAPY (CFT)?
CFT provides a patient centered targeted approach to management of LBP based on a thorough examination. This classification based management approach for LBP considers many domains including: lower back movement and postures, psychological factors, social factors, workplace factors, comorbidities (e.g. diabetes, obesity), pain processing mechanisms: influenced by genetics and life experiences, sleep and lifestyle factors and their relative contributions to an individual’s LBP. CFT challenges thoughts and behaviours in a functionally specific and graduated manner.
It differs from Cognitive Behavioural Therapy (CBT) as changes in beliefs, thoughts and emotions can be realized by the patient when they experience an improvement in symptoms as they move which may challenge previous beliefs, experiences and knowledge about their condition. In a recent study CFT when compared with a manual therapy and exercise group showed clinically and statistically significant large effect sizes across multiple dimensions. The group receiving CFT was 3x less likely to take time off work in the 12 months following treatment1.
As physiotherapists, in a practical sense, it means we are considering both mechanical and non-mechanical aspects of a person’s disorder. By managing patients in this way we are helping them better understand their pain and to move and function in a way that does not perpetuate their pain. By involving the patients in the problem solving and goal setting the longer term prognosis is improved. Essentially this puts patients back in the “driving seat” for directing the course of their rehabilitation and Sarah and I are both excited about the results we are seeing implementing our improved skills so far….
Low back pain (LBP) is very common and is currently the leading cause of disability worldwide3. Only a very small proportion of people with LBP have serious pathology, such as vertebral fracture, cancer, infection or underlying inflammatory disorder, causing their pain2. Unfortunately using a scan to help diagnose LBP is not reliable because MRI abnormalities are as common in those with LBP as in those without. A common recommendation across all high quality LBP guidelines is routine imaging is discouraged unless serious pathology or specific disease is suspected e.g. if surgery is being considered or there has been a limited response to conservative care. There is no evidence that routine imaging improves LBP outcomes. Over time there has been a significant increase in LBP expenditure without any change in associated levels of disability.
Key positive messages supported by current best evidence regarding LBP include:
- The causes of LBP are rarely serious
- LBP has a good prognosis
- Stay active and resume normal activity as soon as reasonable
- Bed rest is specifically not advised
- The back is a strong structure
- Pain does not equal harm
Key management principles for LBP include:
- Diagnosing LBP via thorough questioning and physical examination
- Limited use of imaging
- Advice about what’s contributing to LBP and an understanding of what’s contributing to the pain experience
- Strategies to self-manage pain including physical activity
- Treatment and exercise specific to the problem
- Medication when required but not as the primary management
The key message here is the clear majority of people with LBP, including leg pain (sciatica), will have a good outcome with evidence based, non-surgical care. Cognitive Functional Therapy is an emerging approach to deliver high quality care considering the complexity of factors that can be relevant to a patient’s lower back condition. At Central Bassendean Physiotherapy we pride ourselves on our accurate diagnosis and evidence based, contemporary management of LBP. We are happy to have a further discussion on the material presented here.
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- Vibe Fersum, K, O’Sullivan P, Skouen J, et al. Efficacy of classification based cognitive functional therapy in patients with non-specific chronic low back pain- A randomised control trial. Eur J Pain 2013;17;916-28
- Almeda M, Saragiotto B, Richards B, et al. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018;208(6):272-275.
- Clark S, Horton R. Low back pain: a major global challenge. The Lancet 2018;391(10137):2302.