OARSI emphasizes patient education
Patient education about self-care and lifestyle modifications, such as weight loss, exercise, and pacing of activities to reduce the load on the affected joints, is OARSI’s strongest nonpharmacologic recommendation (SOR: 97%). The guidelines also call for the following interventions:
- correcting mechanical abnormalities of the skeleton;
- helping patients lose weight;
- assisting patients with smoking cessation efforts;6
- directing the use of nonprescription medications;
- prescribing assistive devices; and
- prescribing appropriate prescription drugs.
Nondrug options: Exercise that achy joint
To many patients, being told to exercise a joint in which movement is associated with stiffness and bone-on-bone pain seems counterintuitive. Referring to the findings of the OARSI panel may be helpful in explaining the importance of regular aerobic, muscle-strengthening, and range-of-motion exercises, all of which are strongly recommended (SOR: 96%). Exercise can be as simple as “regular aerobic walking” and home-based strengthening of the quadriceps.4 For patients with arthritic hips, water-based exercises are recommended.
Obesity can increase the risk of developing OA of the hips and knees, and excess weight puts extra stress on joints that are already arthritic. Thus, weight loss is both a risk modification factor (see “Is your patient at risk of OA? Take steps now” ) and a key OA management strategy (SOR: 96%). In a meta-regression analysis conducted by the committee, a reduction of >5% of body weight or a loss at a rate of >0.24% per week was associated with significant improvement in disability. One RCT had a number needed to treat (NNT) of 3 (95% confidence interval [CI], 2-9) to achieve improved pain and function scores after a 2-month low-energy diet.7
Is your patient at risk of OA? Take steps now
Risk factors for osteoarthritis (OA) include:14-19
- mechanical abnormalities, such as varus (bowlegged) and valgus (knock-kneed) angulations;
- flat feet, and heel pronation and supination;
- a history of joint surgery or acute injuries, particularly to the anterior cruciate ligament (ACL) or meniscus;
- obesity;
- manual labor (any job that involves heavy lifting, together with kneeling and squatting);
- participation in competitive or high-intensity sports; and
- a family history of OA (based on mounting evidence of a genetic link).20-22
Lack of neuromuscular control (proprioception) of the knee is another risk factor, since it can expose the internal joint to forces that would otherwise be absorbed by muscle. Exposure of the joint to excess forces can occur if the impact is rapid, leaving the muscle without adequate time to contract to absorb the force, or the muscle is fatigued and weak from prolonged exercise.23,24
Work with patients to modify risk. In discussing risk modification with patients, emphasize that high-intensity running, especially when practiced for years, increases the risk of OA of the knees.25 Indeed, high-impact activity of any kind subjects knee cartilage to significant single and repetitive impact loads and torsional loads.17,26 Point out, however, that some physical activity is needed to maintain normal metabolic activity of cartilage in a healthy joint and that recreational, mild-intensity running or jogging does not appear to increase the risk for OA.27
Be aggressive with knee injuries. As noted earlier, a history of acute ACL or meniscus injury is a risk factor for OA. Knee trauma with effusions that develop rapidly (within 2-12 hours) is associated with high risk of significant intraarticular damage to the ACL, meniscus, and articular cartilage.28 A study of pediatric and adolescent patients who underwent magnetic resonance imaging for possible internal knee injury found cartilage injuries to be the most common.29
To avoid additional damage, manage knee trauma with effusions as a significant injury. Treatment includes bracing, physical therapy, low-impact exercise, and possibly even cross-training or job modification. Advise patients to continue physical therapy until strength and proprioception are fully recovered and no pain or effusion remains, which generally takes about 6 to 8 weeks, and not to return to normal activity prematurely.
Don’t underestimate the power of a phone call
Other nonpharmacologic recommendations include referral to a physical therapist for evaluation and exercise instruction (SOR: 89%); instruction in the use of walking aids, such as a cane or crutch in the contralateral hand, to improve biomechanics (SOR: 90%); and the use of braces to support unstable knees, an unproven intervention that may increase proprioception and stability (SOR: 76%). Physicians should also recommend footwear with insoles or lateral wedges to decrease lateral thrust of the knee and medial compartment forces (SOR: 77%).
Regular telephone contact, possibly on a monthly basis, is a suggested strategy for promoting self-care, tested in patients with OA of the knee but recommended for those with arthritic hips solely on the basis of expert opinion. A number of other modalities, including thermal therapy (heat treatments with warm water or wax, or cold therapy with a 20-minute ice massage), transcutaneous electrical nerve stimulation (TENS), and acupuncture, are recommended for symptom relief.