Clinical FeaturesRheumatology

Exercise and Education: First line treatment for hip and knee osteoarthritis

Osteoarthritis Burden

Osteoarthritis (OA) is a leading cause of disability among older adults and affects upwards of one in eight adults. Due to population ageing along with other factors, this figure is expected to double within one generation. It is a progressive chronic disease characterised by joint pain, stiffness and swelling, which results in significant mobility limitations and poor quality of life in an individual. Irish data from the TILDA study suggests that patients with OA make significant more use of GP and outpatient services than those without OA, at an annual cost of €13.6 million. The highest proportion of direct costs are attributed to orthopaedic surgery and in-patient hospital stays, with smaller proportions accounted for by medications, physician visits, other health professional visits and diagnostic procedures. Substantial indirect costs include productivity losses from absenteeism, presenteeism (disease-related loss in productivity that occurs even when the person is at work), premature death and early retirement (increased social welfare costs and reduced tax revenue).

Current Management

Despite being a typical chronic disease characterised by long duration, current management practices for OA globally are best described as reactive and palliative. Too much focus is on eventual end-stage joint replacement surgery and painrelieving medication strategies in the interim, at a significant cost to society and the individual. Ireland has substantial orthopaedic waiting list times and the lowest number of rheumatology specialists (consultants and physiotherapists) per capita in the European Union. As of the end of February 2023, over 65,000 patients across Ireland were waiting for an orthopaedic outpatient appointment, with 20% of these waiting over a year. Yet, even in the absence of a clear complication, total joint replacement does not always provide relief: up to 30% of total knee replacement patients remain dissatisfied with their surgical result after one year. With the projected growth and cost of this disease, the sustainability of this health-care model is questioned.

OA should be viewed as a chronic condition, where prevention and early comprehensive care models are the accepted norm, as is the case with other chronic diseases. A paradigm shift from tertiary to evidence-based secondary prevention strategies is required, in order to limit progression and minimise the health consequences of the disease.

Clinical Guidelines: Exercise, Education and Weight Loss as First Line of Treatment

What do the clinical guidelines (i.e. OARSI, NICE, ACR and EULAR) say and what is the evidence for each type of treatment? At the bottom of the treatment pyramid (see Figure), every person seeking care for joint pain should be offered the core treatments of education, exercise and weight management (if needed). Metaanalysis shows that we can be confident that land-based exercise therapy effectively reduces pain in patients with knee OA compared to no or minimal intervention. Treatment effect is independent of radiographic severity and pain level with little to no adverse effects so can safely be offered to all patients. The evidence has not shown that one type of exercise is better than another. However, we do know that the exercise has a better effect if supervised by a physiotherapist, and a minimum of 2-3 times weekly is necessary to get the effective dose. It is generally recommended, based on the literature, that 3-5kg, or losing 5% of your baseline weight will relieve pain and improve function for people with OA who are overweight. In 2020, a metaanalysis including 22 studies and 3602 patients with OA looked at weight loss interventions versus minimal care. Weight loss was observed to be effective for moderate pain relief in hip and knee OA but is best combined with exercise and education for optimal results in pain and function.

Clinical Guidelines: Adjuncts as Second Line of Treatment

If the first line of treatment doesn’t lead to a satisfactory outcome, it can be complimented with adjunct treatments such as pain medications, TENS, manual therapy, braces, shoe insoles, other aids, and in some instances injections. However, these strategies cannot address the range of factors contributing to pain and disability. For example, the only way to improve your strength is to complete an exercise program. Second-line treatments usually only incur short-term benefits, some are high risk and almost all are more costly. The most common types of pharmacological pain relief used by people with OA are 1 – paracetamol, 2- Nonsteroidal anti-inflammatories (NSAIDS) and 3- opioids. According to the latest OARSI 2019 guidelines, paracetamol is conditionally not recommended (at Level 4A and 4B), and this is a recommendation that many are not yet aware of. A 2021 meta-analysis found that found that topical NSAIDs are more effective than paracetamol, but not more effective than oral NSAIDs to improve function. However, it noted that topical NSAIDs are safer than paracetamol and oral NSAIDs due to a lower association with all-cause mortality, with cardiovascular disease and with gastrointestinal bleeding. All guidelines strongly recommend against the use of opioids due to low effect and high risk of adverse events. Intraarticular glucocorticoid injections may be considered for the medical treatment of knee OA but only in a timely manner, considering they have no benefit after 6 weeks, and repeated injections of cortisone over 2 years leads to more rapid cartilage loss. Other adjuncts such as TENS, manual therapy, braces, shoe insoles, dietary supplements, other aids may have a positive effect that is short-term and not much more than a placebo effect. However, most have no side effects. Secondline treatments should never replace the core recommended treatments of exercise, education and weight loss.

Clinical Guidelines: Surgery as Third Line of Treatment

And at the top of the treatment pyramid, for those with very severe symptoms (10-15%), surgery may be considered. This should be a last resort, since surgery is associated with adverse effects, such as joint infection and blood clots that can be life threatening. About 20% experience one adverse event and rates of dissatisfaction in the knee are up to 30%. Joint replacement surgery is most effective when indicated. On the other hand, arthroscopic knee surgery has no better effect than a sham or placebo and should not be offered.

GLA:D Ireland – An Example of an Evidence-based Management Programme

GLA:D (Good Life with osteoArthritis Denmark) is a non-profit initiative that has addressed a gap in osteoarthritis care by training and supporting physiotherapists to implement guidelines for hip and knee OA (exercise and education) in clinical practice. Since 2013, the programme has trained over 6,000 clinicians and over 100,000 patients have benefitted from the programme across 4 continents. Research data from the GLA:D programme tells us that patients can expect decreased pain and have improved function and quality of life up to one year after taking the programme. The programme includes 12 supervised neuromuscular group exercise sessions, twice per week, and 2 education sessions, with inclinic or online delivery options. To support research related to the programme, the GLA:D Ireland National Register collects physiotherapist- and patientreported outcomes electronically at 3- and 12-months post programme delivery. Initial funding for the GLA:D Ireland programme was granted by a Health Research Board Emerging Investigator Award. There are over 70 GLA:D trained physiotherapists in Ireland currently and we plan to continue delivering 2-3 courses per year for physiotherapists across public and private health sectors. If you are interested in finding out more about GLA:D, join our mailing list by emailing gladireland@ul.ie or take a look at our website: www.gladireland.ie.

Dr Clodagh Toomey is a Physiotherapist and Research Fellow at the School of Allied Health, University of Limerick. Clodagh completed her PhD at the University of Limerick in 2014 and a Postdoctoral Fellowship in 2017 at the Sport Injury Prevention Research Centre, University of Calgary, where she also holds an adjunct position. Her clinical and research experience has focused on prevention and management of musculoskeletal disease across the lifespan. Most recently, she was a recipient of a Health Research Board Emerging Investigator Award, which is investigating how to optimise implementation of clinical guidelines for osteoarthritis in practice. Clodagh is the research lead on the Good Living with osteoArthritis Denmark (GLA:D®) initiative in Ireland

Written by: Dr Clodagh Toomey, School of Allied Health, University of Limerick

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