Osteoarthritis: The Gateway Problem?

Osteoarthritis is one of the most common points of entry to the physio clinic. I feel that it’s a “gateway” condition — once people find out that they have arthritis, sometimes they talk as if it’s only downhill, as if their pain and functioning will only get worse.

But “getting worse” is not an option that I want to consider as a physio. So, in this week’s Physio Weekly, we’ll review some studies to help you get the best results with patients with hip or knee osteoarthritis.

Exercise + Pain Coping Skills = Improved Quality of Life

I want to treat the whole person, not just the hip or knee. What is the evidence that we can really improve quality of life for those with osteoarthritis?

A 2018 review explored what types of interventions actually improve quality of life and psychosocial factors for those with knee osteoarthritis. Although the authors found that exercise does improve quality of life, they made no specific recommendations about type of exercise.

One of the most important psychosocial factors for treating OA is self-efficacy — which is essentially the ability to do whatever it takes to accomplish a task. In order to improve self-efficacy in knee OA, there is some evidence that adding pain coping skills training may be more effective than exercise alone. 

In other words, help your patients learn to cope with pain, and get them moving.

Dosing Exercise for Osteoarthritis 

Most of us would say exercise is essential, but what dose of exercise is best? 

A 2018 review of exercise dosing found that at least 24 exercise sessions provide the most benefit, over an 8- to 12-week period. Exercise sessions should be at least 20 minutes.

The benefits of exercise for hip and knee osteoarthritis.

Physical activity is effective at preventing as many as 35 chronic diseases and at treating 26 chronic diseases, including cardiovascular disease, type II diabetes, and depression. Skou et al provide seven key exercise recommendations for those with hip and knee osteoarthritis:

1. Provide aerobic, resistance, performance or neuromuscular exercisestailored and targeted to individual patient needs and preferences.

2. Consider aquatic exercise in patients who are unable to adequately complete land based exercise due to pain.

3. Provide a minimum of 12 supervised exercise sessions of 30-60 minutes per session, over a six week period – i.e. two sessions per week.

4. Encourage an additional 1-2 sessions per week to optimize outcomes, particularly related to strength.

5. Consider extending initial exercise therapy programs to 12 weeks or longer to optimize outcomes, particularly related to strength.

6. Include patient education and consider booster sessions in the long term to enhance adherence and progression.

7. Provide education and reassurance about managing potential pain flares and inflammation, and how to modify exercises and physical activity to ensure continued participation.

Exercise Is the Best Exercise

But wait. When you prescribe exercise for your patients, does the type of exercise matter?

The Orthopaedic Section published a 2017 revision of the clinical practice guidelines for hip osteoarthritis. The guidelines recommend that there is strong evidence for prescribing flexibility, strengthening, and endurance exercises for mild to moderate hip osteoarthritis at a dosage of 1 to 5 sessions per week for 6 to 12 weeks.

But if you’re like me, then “flexibility, strengthening, and endurance” is not specific enough. What kinds are the best?

Recent papers from Bieler and colleagues show how hard it is for one type of exercise to outperform another in hip osteoarthritis. Their 2017 paper examined the differences of 4 months of supervised strengthening exercises vs. Nordic walking vs. unsupervised home exercises. The supervised strengthening exercises included machine exercises aiming for sets at 10 RM. The Nordic walking group included trail walking for 3-4 km to start and progressing distance and speed. The home base exercise group used a chair stand exercise, a pelvic lifts, isometric hip flexion exercise in standing, and a gluteus medius exercise in sidelying.

Which exercise was most effective? 
There were no significant between group differences for improvements in muscle strength and power or range of motion at any time point. The strength training group and the Nordic walking group reported less pain at 4 months than the home-based exercise group. The Nordic walking group outperformed the other two groups at all time points in other functional measures like the 6-minute walk test. However, the Nordic walking group had the highest level of dropout.

I think it is fascinating that the Nordic walking group may have had the greatest results but also seem the least desirable.

Prove the Return on Investment

What performance measures should we use to set goals in hip/knee osteoarthritis?

Master and colleagues found that these three measures predict function difficulties with knee OA:

  • >11.4-14.0 seconds on a 5 times sit-to-stand test
  • <1.13-1.26 m/s gait speed
  • >315-349 seconds on a 400-m walk test

These are good measure to use when you are setting goals with patients with knee OA.

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