Osteoarthritis: treatment beyond the prescription pad
Published on 05 December 2014
Dr Tom Margham gives a GP view on how to live with osteoarthritis.
Betty Jones is 74-year old and has type 2 diabetes, high blood pressure and chronic kidney disease. She also suffers with painful knees. She’s been experiencing increasing pain for the last five months, which is now interfering with her sleep and everyday activities. She was diagnosed with osteoarthritis four years ago and has been managing pretty well since, using anti-inflammatory creams and occasional paracetamol.
Someone like Mrs Jones would be familiar to most GPs. We recognise the limitations of what we can offer to our patients when it comes to medications for the pain of osteoarthritis. Oral non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen and diclofenac, aren’t usually advised due to their risk of causing stomach or kidney problems. Anti-inflammatory creams and gels are modestly effective and paracetamol is often of limited value in terms of its effect on pain.
The lack of really effective drug options for osteoarthritis forces us to be more creative in the ways to help people manage their joint pain. The updated NICE guidelines on osteoarthritis, published in February 2014, clearly highlight the wide range of non-drug treatments available, from supports and bracing of the joints and insoles for shoes through to physiotherapy (especially for hip osteoarthritis) and assistive devices such as tap-turners or washing aids. My approach in practice is a pragmatic one. In the absence of ‘magic bullets’ when it comes to managing the symptoms of osteoarthritis, I aim for a combination of management options which, whilst on their own may only offer a small benefit, when used in combination may have an bigger effect. Another guiding principle is that treatments for osteoarthritis should ideally be simple, effective (and cost-effective), safe and ideally self-administered.
So what’s happening in a joint affected by osteoarthritis? There is a constant process of wear and repair happening as the joints adapt to the stresses and strains of normal everyday life. Osteoarthritis occurs when the process of wear and repair goes out of balance – for example due to injury or being overweight – which leads to pain, stiffness and swelling in the joints.
When we discuss osteoarthritis treatment, it’s important to remember that with the exception of joint replacement, we’re not talking about treatments that actually change the disease process in the joint. Instead we focus more on symptoms, the impact of the condition on the ability to carry on with everyday activities (we medics call it ‘function’) and quality of life.
Right at the centre of the NICE recommendations are the core treatments of exercise, weight loss (if you’re overweight), education, advice and access to information. This advice should be given to all people with osteoarthritis and will be explored in more detail in the rest of this article.
Access to information: start with a diagnosis
Access to effective treatment starts with a positive diagnosis. Osteoarthritis can be diagnosed by GPs following a clinical assessment and without the need for x-rays in the majority of cases. Giving patients a positive diagnosis of osteoarthritis, rather than describing it as merely (a touch of) ‘arthritis’ or a (bit of) ‘wear and tear’ allows people to access the right information so that they can begin to find out about living and coping with their condition.
Osteoarthritis is usually diagnosed if a person:
- is 45 or over
- has activity-related joint pain and
- has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.
Early morning stiffness lasting 30 minutes or longer may be due to an inflammatory arthritis such as rheumatoid arthritis – if you have this you should see your GP to discuss your symptoms.
Weight loss if overweight
This is an interesting part of the NICE guidelines. Most of the published research is about hip and knee osteoarthritis, and the overwhelming majority is on knee osteoarthritis. So the advice around losing weight, for example, is mainly focused on knee osteoarthritis, though the authors of the guideline concluded that advice to lose weight was sensible across the board.
Every time we take a step, the force of three to six times our bodyweight goes through our knees, so the link between weight and load through the knee is clear. If you are overweight, reducing your body mass index (BMI) by two units reduces the risk of developing osteoarthritis of the knee by 50%. Which for a woman of average height equates to approximately 5 kg (12 lb) weight loss – a modest target.
Interestingly the link between weight loss and improvements in pain in people who already have knee osteoarthritis is less clear-cut. Weight loss of approximately 5% body weight or at least 6kg (14 lb) leads to noticeable improvement in the way people move and feel, but the direct link with improved pain is not as strong. However, the research shows that combinations of diet AND exercise lead to more weight loss, less pain, better function, faster walking speed, further walking distance and better health-related quality of life than diet or exercise alone.
Exercise is one of the most effective, safe and cost-effective weapons in our arsenal when it comes to managing the symptoms of osteoarthritis, and is roughly as effective as oral NSAIDs for knee osteoarthritis but without the side-effects. But there are challenges to overcome. Being affected by osteoarthritis can lead to a vicious cycle: it hurts more to move so a natural response is to move less, then people get weaker and stiff and quickly become deconditioned with rapid loss of muscle bulk, strength and endurance. So when they do move the muscles are weaker and joints are less stable so they experience pain and fatigue more readily. When people with osteoarthritis first start exercising they often experience more pain; I always warn them about this so that they are encouraged to persevere.
Myth buster: Exercise is not going to wear out your joints quicker
We need to be ready to bust the myths surrounding osteoarthritis. Using your joints helps keep them strong rather than wearing them out more quickly. And when you experience pain when moving, ‘hurt does not mean harm’. Research has highlighted that people with osteoarthritis want to be more active but are worried about making their pain, or their condition worse, and are looking for ‘permission’ to get more active from their GP or practice nurse. I’ve found that starting a conversation around exercise along the lines of “What would you like to be able to do now that you can’t do because of your joint pains?” can kick off a really positive and constructive conversation with my patients.
The kind of exercise helps most for OA is generally a mixture of:
- resistance: for strength and joint stability
- aerobic: for fitness endurance and mood
- flexibility: for balance, range of movement and co-ordination.
The benefits of exercise far outweigh the risks, the main risk being injury. The risk of injury can be reduced by warming up and cooling down properly. ‘Start low and go slow,’ gradually increasing the amount and intensity of exercise, wear well-fitting, supportive, shock-absorbing footwear and avoid high loading (e.g. jumping and twisting) to start with.
Top tips for exercise
- Any physical activity is better than none.
- Start low and go slow.
- The benefits of exercise are related to the amount that you do – i.e. more is more.
- It will take around six weeks of regular exercise to start to experience benefits – so stick with it!
- The ‘dose’ of exercise is at least 30 minutes three (or more) times a week for aerobic exercise and at least 20 minutes three times a week of resistance exercise. This can be broken down into five- or ten-minute chunks
- People who stick with exercise benefit the most in the long-term. So find something you enjoy doing – and do it!
- Things like exercise diaries, pedometers, and supervised and group exercise programmes can help you to stick with exercise.
- Exercise is a perishable good. In order to be effective, exercise must be ongoing – especially in the older population who need to train harder to maintain the same benefits.
Read more about exercise and arthritis
Dr Tom Margham is Arthritis Research UK’s primary care lead and a GP in Tower Hamlets.