Osteoarthritis of the knee, in Chicago and elsewhere

"I don’t like moving, eat much, put on weight. ...am I surprised to have pain in my knee?"

...my patients often repeat.

With the increase in the ageing population and in risk factors for poorer health such as obesity and reduced physical activity, musculoskeletal conditions such as osteoarthritis (OA) will be the main cause of physical disability in older adults. Support for self-management is therefore a priority and the use of core treatment in the management of OA is a key implementation objective.

The core approaches include: access to written information and advice; support for self-management; healthy eating and healthy weight; joint protection and reduction in joint load; simple analgesia; and advice on exercise and physical activity.

I. BASE THERAPY

1. Education and information access

   
   

It is a professional responsibility to inform patients of their diagnosis and prognosis, to explain tests, and to discuss treatment options. This enhances understanding of OA and its management, and counters misconceptions—for example, that OA inevitably progresses and cannot be treated. Access to such informations beneficially influences outcome and can be regarded as treatment.

When studied in OA, access to information has been shown to reduce pain and disability, improve self-efficacy and coping skills, and reduce the frequency of rheumatology consultations and health costs. Educational techniques and motivational interviewing, eg. individualised education packages, regular telephone calls, group education. patient - and spouse assisted coping skills training. Education can also use written literature, videos or internet tools. Information sharing and reinforcement should be an ongoing, integral part of management.

2. Advice on exercise and activity

   
   

Joints are built to move and the health of all integral components of the joint depends on regular movement. If a joint is compromised by OA, it is even more important to maintain movement. Two types of exercise can reduce pain and disability on the long term and both should be prescribed to anyone with large joint OA, irrespective of age:

• aerobic exercise (fitness training) and increased activity, which improves wellbeing, encourages restorative (delta) sleep and benefits common comorbidities such as obesity, diabetes, chronic heart failure and hypertension.

• local neuromuscular training, strengthening, and range of motion exercises for quadriceps and gluteal muscles. This can greatly improve the detrimental physiological accompaniments of large joint OA, specifically reduced muscle strength, reduced knee proprioception, impaired standing balance, and increased tendency to fall. Such benefits are modest but long lasting if adherence is maintained.

The American College of Rheumatology (ACR) 2012 recommendations for the management of knee OA and hip OA also include aquatic exercises, medially directed patellar taping, manual therapy and tai chi. A network meta-analysis comparing different packages of exercises for lower limb OA, predominantly knee OA, demonstrated that combinations of exercise to increase strength, flexibility and aerobic capacity are likely to be the most clinically effective. Alternatively, hand exercises delivered in classes by occupational therapists were found to be cost effective.

Patients should be advised to balance activity and rest, breaking up long periods of activity (such as walking around the shops, housework and gardening) with frequent short rest periods. Although this means that specific physical tasks take longer to do, they are often completed successfully and with less mechanically induced pain as a result. Patients should be informed that the physical training should be done on a continuous, regular basis.

3. Reduction of adverse mechanical factors

   
   

Obesity is a common comorbidity and an important modifiable risk factor for knee OA. The principles of education about weight management are detailed in the recent EULAR recommendations. Trials of weight loss in obese/overweight patients with large joint OA show clear improvement in function and in pain. Successful weight loss programmes recommend: frequent self-monitoring, both diet and exercise, regular eating, good food variety but reduced portion size, low (saturated) fat and sugar and high fruit and vegetable content, nutritional awareness through education, and modification of eating triggers (eg, stress).

Patients with knee and hip OA should be advised about appropriate footwear. Shoes with thick but soft (eg. air-filled) soles and no raised heels minimise adverse knee, hip and back alignment when walking - such shoes should be advised for all patients with knee and hip OA.

Review of the effectiveness of the use of lateral wedged insoles in patients with medial knee OA found no significant benefit on pain or function. Medial wedged insoles have been recommended for patients with lateral tibiofemoral OA or mild valgus malalignment. There is no clear evidence to support the use of one type of insole over another, and adverse effects including foot sole, low back and popliteal pain have been reported. The recent EULAR non-pharmacological guidance document does not recommend the use of wedged insoles.