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OSTEOARTHRITIS

Non-Surgical management of osteoarthritis

Why sole the problem of osteoarthritis?

Why try solve the problem of osteoarthritis? It is really pretty simple. Osteoarthritis hurts, and because it hurts people stop being active and put on weight (Rosenmann et al, 2008). As a result you go from just having a “sore bit” to having the consequences of being inactive and being overweight. These include high blood pressure, diabetes, heart disease, depression and increased mortality (Rosenmann et al, 2008, Blair et al, 1999, Paffenbarger, et al, 1993).

Worldwide there are 9.6% of men and 18% of women over the age of 60 who suffer osteoarthritis. In Australia there are 3.5 million who suffer osteoarthritis, with 19,000 hip and 20,000 knee replacements performed each year (March and Bagga, 2004). With the population of those over 60 expected to reach 2 billion by 2050 (WHO, Aging Life course) this will result in approximately 200 million people suffering OA worldwide.

If we can improve the osteoarthritis of 1% of those people, we can change the lives of 35,000 people in Australia and 200,000 around the world. And this will not only effect those individuals, but their families, friends, work colleagues and thus our society.

 

Managing the pain first

Managing the pain first:

Patients with osteoarthritis are commonly told to go and do some exercise, and lose some weight. They are provided with some paracetamol or anti-inflammatories and sent on their way. But unfortunately, lots of people don’t like taking medications and thus, they can’t do exercise because they still have pain. Further to this, because they can’t do any exercise, they can’t lose weight .

The basic premise of this treatment approach is to settle the patients’ pain first. Once this has begun, then commence an exercise program. Once they are exercing, then encourage weight loss. Doing it sequentially rather than concurrently makes it more achievable and is generally well received. 

 

Dr Dan Bates - Decrease pain, gradually increase activity, then decrease weight

Why manage osteoarthritis as a chronic pain disorder

Osteoarthritis as a Chronic Pain Disorder:

Osteoarthritis is seen by many patients and clinicians as a degenerative joint disease due to wear and tear, with the absence of cartilage being the primary reason why patients have pain. However, articular cartilage does not have nerves and 40% of people with X-ray changes consistent with osteoarthritis do not have pain (Sofat et al, 2011). Further to this, when you look at the population as a whole, the degree of joint degeneration on X-ray (Kellgren–Lawrence classification) correlates poorly with degree of pain. This indicates that more just joint damage is responsible for the intensity of pain suffered by osteoarthritis patients (Lee et al, 2011).

Chronic pain model for osteoarthritis

The Chronic Pain Model of Osteoarthritis

Osteoarthritis may be seen as a chronic pain disorder. Seeing it in this fashion opens up the treatment options from the single solution of replacing the joint, to multiple options of decreasing the pain and returning function.

Chronic pain can be thought of like a rock band with guitars, amplifiers and speakers, each component having its own volume control. The guitar is the joint or body part that hurts. There are a number of things that can “play” the guitar thus turning the volume (pain) up or down at the site of injury or degeneration.

In the case of osteoarthritis these can be split in to 4 main groups

  • Synovitis
  • Bone oedema
  • Mechanical issues eg meniscal tears and loose bodies
  • Modifiable factors eg Muscle strength, balance, trigger points, reducible joint deformity and foot alignment

Each one of the above needs to be identified and addressed.

The guitar is then plugged into an “amplifier”. The amplifier is the spinal cord. Changes in the spinal cord mostly occur in the dorsal root ganglion, with complex alterations in neurotransmitters, receptors and a loss of inhibitory neurons. The overall effect is a loss of pain inhibition and an effective “turning up” of the amplifier’s volume.

Finally, the amplifier is plugged into the “speakers”, which is the patients’ brain and the place the pain is “heard”. The speakers also have a volume control. Simply put; if you have a bad day, things hurt more. This is turning the “volume control” (pain) in your head up. Similarly, if you have a good day, or go on holiday the pain is commonly less.

The system can be split in to the amplifier and speakers (central sensitization) and the guitar and its players (peripheral sensitization).

From a practical perspective pain in osteoarthritis can be thought of as:

 Dr Dan Bates - Chronic pain model of osteoarthritis

 

The algorithm the creates a practical approach to using the Osteoarthritis Research Society International (OARSI) Guidelines for the management of osteoarthritis.

Response to the treatment approach

Response to a non-surgical management approach for osteoarthritis

These results a based on patient outcome measures taken from patients during treatment. Overall, based on visual analogue scale (VAS) and Knee Osteoarthritis Outcome Score (KOOS) 75% of people respond to the treatment approach.

Of those that respond who have pain ≥5/10 on average at the beginning of treatment

Response on VAS (Percentage decrease in pain)

  • 40% decrease in average pain,
  • 25% decrease in most severe pain
  • 35% decrease in least severe pain

On KOOS (Percentage changes in quality of life, symptoms, pain, activities of daily living and sportsing activity)

  • 95% improvement in sports and recreation
  • 60% improvement in Quality of life
  • 30% improvement in Symptoms
  • 25% improvement in Activities of daily Living
  • 23% improvement in Pain


Of those that respond who have pain <5/10 on average at the beginning of treatment

On VAS (Percentage decrease in pain)

  • 60% decrease in average pain
  • 55% decrease in worst pain
  • 45% decrease in least pain

On KOOS (Percentage changes in quality of life, symptoms, pain, activities of daily living and sportsing activity)

  • 160% improvement in sports and recreation
  • 39% improvement in Quality of life
  • 18% improvement in Symptoms
  • 20% improvement in Activities of daily Living
  • 22% improvement in Pain

These results are not published in a peer review journal and can only be taken as a guide to possible outcome. Patients are individuals and will respond differently (hopefully better though).

 

References

 

Blair SN, Brodney S. Effects of physical inactivity and obesity on morbidity and mortality: current evidence and research issues. Medicine & Science in Sports & Exercise 1999;31:S646–62.

Bennell, K. L., & Hinman, R. S. (2011). A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. Journal of science and medicine in sport / Sports Medicine Australia, 14(1), 4–9. doi:10.1016/j.jsams.2010.08.002

Christensen, R., Bartels, E. M., Astrup, A., & Bliddal, H. (2007). Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis. Annals of the rheumatic diseases, 66(4), 433–9. doi:10.1136/ard.2006.065904

http://www.who.int/ageing/en/ Ageing life course, Last accessed November 27 2012.

Lee, Y. C., Nassikas, N. J., & Clauw, D. J. (2011). The role of the central nervous system in the generation and maintenance of chronic pain in rheumatoid arthritis, osteoarthritis and fibromyalgia. Arthritis research & therapy, 13(2), 211. doi:10.1186/ar330

March, L.M. and Bagga, H (2004). Epidemiology of osteoarthritis in Australia. Medical Journal of Australia, 180(5), S6-10.

Rosemann T, Grol R, Herman K, Wensing M, Szecsenyi J. Association between obesity, quality of life, physical activity and health service utilization in primary care patients with osteoarthritis. Int J Behav Nutr Phys Act 2008;5:4.

Paffenbarger RS, Hyde RT, Wing AL, Lee I-M, Jung DL, Kampert JB. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. N Engl J Med1993;328:538–45.

Tanna S, Priority Medicines for Europe and the World “A Public Health Approach to Innovation” archives.who.int/prioritymeds/report/…/osteoarthritis.doc, 2004

Sofat, N., Ejindu, V., & Kiely, P. (2011). What makes osteoarthritis painful? The evidence for local and central pain processing. Rheumatology (Oxford, England), 50(12), 2157–65. doi:10.1093/rheumatology/ker283

 

 

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