KNEE OSTEOARTHRITIS (OA) A physiotherapist s perspective When to refer?
Beyond Wear & Tear Traditional & still common viewpoint Wear & tear Degenerative joint disease Progressive destruction of articular cartilage Bone on bone = disaster The beginning of the end! MRI studies = only weak associations between cartilage volume/thickness & knee pain Articular cartilage is mostly aneural & avascular
What is Osteoarthritis? Osteoarthritis is a disorder involving movable joints characterized by cell stress and extracellular matrix degradation initiated by micro- and macro-injury that activates maladaptive repair responses including proinflammatory pathways of innate immunity. The disease manifests first as a molecular derangement (abnormal joint tissue metabolism) followed by anatomic, and/or physiologic derangements (characterized by cartilage degradation, bone remodeling, osteophyte formation, joint inflammation and loss of normal joint function), that can culminate in illness. OARSI, 2015
Synovium Capsule Bone Cartilage Ligaments Muscle ENVIRONMENT Wear & Repair Anatomical & Physiologic Derangement May or may not be progressive
OA is a Heterogeneous Condition Symptoms vary from person to person Imaging does not equal clinical presentation Rate of progression variable Progression not guaranteed Osteoarthritis symptoms will not always get worse, and will not always require an operation French et al AC&R 2014
Osteoarthritis Impact Depression Pain Psychosocial issues Anxiety/Fear Catastrophising Muscle weakness Swelling Joint instability Physical impairments Comorbidities Obesity Diabetes CV disease Joint stiffness Malalignment Impaired balance Reduced fitness Reduced function Sleep/fatigue Lower quality-of-life
Priorities for Care Pain Function Quality of Life Slowing of structural disease progression All guidelines focus on non-drug, non-surgical, self help, patient driven strategies rather than passive strategies driven by clinicians Bennell, Hall & Hinman, 2016
Education Exercise Pilates Acupuncture Thermotherapy Manual Therapy Physiotherapy Bracing Massage Therapeutic ultrasound Weight Loss Footwear & Foot Orthoses Gait aids & gait retraining TENS
Physiotherapy Poor knowledge of utility of physiotherapy by many patients and health professionals for the management of OA knee Of non-surgical, non-pharmacological key recommendations: On average ~25% utilisation 12% = zero utilisation Hinman et al. 2015 Common physio belief that exercise is no benefit in severe knee OA Holden et al. 2008
Insufficient Evidence or Evidence Not Proceed Therapeutic Ultrasound Laser therapy Acupuncture
Some Evidence Still Worthy of Consideration Thermotherapy TENS Massage Comfort Measures Manual therapy Braces Footwear Gait aids Potentially Load Modifying Gait retraining
Key Treatment Recommendations in all Clinical Guidelines Education Weight loss Exercise
Education Address belief structures in general and specific terms Face to face + information + referral NICE 2014 Failed conversation Wear and tear, progressive, not much we can do Leads to cessation of physical activity Leads to increase sedentary behaviour
Adjunctive Education 100% Quality of Web Based Osteoarthritis Education 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Orthopaedic Surgeon Rheumatologist Sports & Exercise Physician Hospitals (Private) Hospitals (Public) Excellent Very Good Good Fair Poor
Minimalist approach is ineffective Rheumatologist Booklet and video demo only Unsupervised Standardised program No follow-up No benefit compared to usual care after 6 months Ravaud et al. Ann Rheum Dis 2004
Weight Loss Only beneficial if overweight Reduction in both pain and disability Only a relatively small amount of weight loss needed to significantly improve disability 5.1% body weight At least 0.24% reduction per week Christensen et al. 2007 Best achieved with both diet and exercise (IDEA trial) Hunter et al. 2015
Goals of an Exercise Program for OA 1. Preserve or restore ROM & flexibility around affected joints 2. Increase muscle strength and endurance 3. Increase aerobic conditioning to improve mood and reduce health risks associated with a sedentary lifestyle Hoffman (1993), Arthritis and Exercise, Primary Care, 20, 895-910.
Benefits of exercise Weight control Improved physical & psychological health Associated with less co-morbidities Low cost Safe Reduced all cause mortality
Effects of land-based exercise Fransen et al Cochrane Review 2014
Exercise is as effective as drugs Zhang et al Osteoarth Cart 2010
Effect sizes for different exercise types Effect size p>0.05 p>0.05 Fransen et al Cochrane Review 2014
Effect of Intensity Leg press exercise WOMAC Pain 3 x per week for 8 weeks High intensity = 60% 1 rep max Low intensity = 10% 1 rep max Jan et al. Phys Ther 2008
Exercise Compared to Joint Replacement Randomised trial Patients eligible for joint replacement Exercise vs TKJR + Exercise Both groups improved significantly Significantly more adverse events in surgery group Skou et al NEJM 2015
Hydrotherapy/Aquatic Therapy Not superior to land based exercise Benefits of buoyancy & heat Ability to control load bearing Irritable joints Deconditioned patients Progression to land based exercises Zhang et al. 2010
Exercise Recommendations Strong evidence for exercise but no superior mode or parameters Individualised All levels of severity Self management programs Strengthening (local & global) Low-impact aerobic exercises Neuromuscular education
Epworth Richmond & Camberwell Arthritis Programs OA (hip & knee) All arthropathies Multidisciplinary Richmond Camberwell (DT, OT, PT, Hydro & Psych) Twice weekly for 8 weeks Education Exercise Refer by e-mail: rehab@epworth.org.au
Epworth Camberwell Pilot Outcomes All patients had clinically significant improvements on standardised gait tests All patients demonstrated clinically significant increases in muscle strength and flexibility 50% demonstrated improved WOMAC scores (Pain and Physical Function) Nil significant changes to DASS21 100% patient reported very helpful 80% patients perceived significant improvement 30
Summary When to Refer? Physiotherapy is indicated in the majority of knee OA patients Non-invasive Safe Important element of conservative management that should usually precede surgery Physiotherapy well placed as a key player in applying evidenced based management Exercise Education Weight Loss