Which treatments are people with osteoarthritis actually using?

It has been well established that hip and knee osteoarthritis (OA) is one of the major causes of disease burden worldwide. There is currently no cure and joint replacement is typically reserved for advanced disease, whilst arthroscopy has been shown to have little or no benefit. For over 10 years now there has been substantial evidence supporting non-drug non-operative management strategies as the cornerstone of OA treatment (1).

All current clinical guidelines recommend aerobic exercise, resistance exercise, hydrotherapy and weight loss (for those who are overweight) for people with hip or knee OA. The American College of Rheumatology (ACR) guidelines strongly recommend these four interventions for all people with hip and knee OA, irrespective of disease severity, pain levels or functional status (2). In addition, a myriad of patient resources, websites, and consumer groups strongly support the use of these evidence-based interventions. But is this translating into action?

Our recent short report in Arthritis Care and Research examined the patterns of use of non-drug non-operative interventions, classified according to the ACR guidelines, among a large cohort of older adults with hip or knee OA (3). We also compared treatment use between those with hip and those with knee OA. To do this, 591 participants completed a survey on treatment usage prior to taking part in a number of clinical studies.

So what did we find? Perhaps not entirely surprisingly the use of non-drug non-operative interventions was low amongst the entire group of people with hip or knee OA. Participants were currently using a mean of less than one of the four strongly recommended interventions. Concerningly, 12% of the group had never used any of the interventions included in the questionnaire.

Making efforts to lose weight (50%) and shoe orthoses (30%) were the most commonly reported interventions being currently used. Our cohort was generally overweight to obese, thus weight loss was warranted in many participants. Strengthening (26%) and stretching (23%) exercises were the most common interventions that participants reported they had tried in the past but were no longer utilising. Although half reported making efforts to lose weight, very few were undertaking muscle strengthening, hydrotherapy or aerobic exercises, all of which are the strategies most strongly endorsed by international guidelines.

Interestingly, use of five treatments was significantly higher among those with knee OA than those with hip OA. It appears that people with knee OA are more likely to try non-drug non-operative treatments than those with hip OA, however there is no clear explanation for this.

So what are we to take from the findings, other than that there is a definite evidence-practice gap? Weight loss and exercise should be the first course of action in managing hip and knee OA. Both have well established research demonstrating their benefits, but are still being under-utilised by clinicians and patients. This questionnaire did not allow us to explore whether interventions had been prescribed by a health professional or were self-prescribed, but we know there is still uncertainty among both groups around the use and benefits of exercise for OA (4, 5). Improved and increased education is required if we are to move forward – an ongoing challenge for us all in bridging the evidence-practice gap.

About Kim Bennell

Kim BennellKim is a Professor and Director of the Centre for Health, Exercise and Sports Medicine at the Department of Physiotherapy, University of Melbourne, and an NHMRC Principal Research Fellow. Her research is focused on the conservative management of musculoskeletal conditions particularly osteoarthritis. Kim has published over 250 papers and given over 100 keynote or invited presentations at interdisciplinary meetings around the world. Kim currently holds a NHMRC Program grant and Centre of Research Excellence with colleagues from the University of Queensland and University of Sydney. http://chesm.unimelb.edu.au/

References

1. Uthman OA, van der Windt DA, Jordan JL, Dziedzic KS, Healey EL, Peat GM, & Foster NE (2013). Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ, 347 PMID: 24055922

2. Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G, Tugwell P, & American College of Rheumatology (2012). American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis care & research, 64 (4), 465-74 PMID: 22563589

3. Hinman RS, Nicolson PJ, Dobson FL, & Bennell KL (2015). Use of nondrug, nonoperative interventions by community-dwelling people with hip and knee osteoarthritis. Arthritis care & research, 67 (2), 305-9 PMID: 25048646

4. Holden MA, Nicholls EE, Hay EM, & Foster NE (2008). Physical therapists’ use of therapeutic exercise for patients with clinical knee osteoarthritis in the United kingdom: in line with current recommendations? Physical therapy, 88 (10), 1109-21 PMID: 18703675

5. Holden MA, Nicholls EE, Young J, Hay EM, & Foster NE (2012). Role of exercise for knee pain: what do older adults in the community think? Arthritis care & research, 64 (10), 1554-64 PMID: 22511582

Comments

  1. Hi Kim,
    As you know I think the work being done to elucidate and inform re evidence for better outcomes is vital. Keep up the great work.
    What interests me is that the current prevailing and widely taught bio-model based paradigm contains an intrinsic ‘nocebo’ inducing component. On many occasions this is overt eg: “don’t do this/that/the other or you will get worse”; but sometimes very subtle eg: the everyday terminology that we use.
    There is not a medical discourse / conference where I do not grind my teeth when I hear terms like “degenerative disease”.
    Please consider the following –
    The OVERWHELMING majority of degenerative changes are either asymptomatic or minimally symptomatic ie: structural and neuroplastic adaptation occurs naturally until a maladaptation occurs and then we treaters mess with it physically, psychologically and neurophysiologically.
    Consider this stated observation (? a fact), and also that the word ‘disease’, while defined variably, is generally typified by eg: “an impairment of the normal state of the living animal or plant body or one of its parts that interrupts or modifies the performance of the vital functions, is typically (please consider this word bolded and italicised as I can’t do this on this post!) manifested by distinguishing signs and symptoms etc … (http://www.merriam-webster.com/medical/disease)
    Then … does ‘degeneration’ actually constitute a ‘disease’??

    In my opinion it may help our patient’s compliance with solid conservative management protocols if we created a paradigm shift such as simply stopping to refer to degeneration as ‘ disease’ but perhaps just periodic maladaptations of normal processes when episodic inflammatory or nociceptive events occur as input to pain and pain related disability.
    An extreme and very common example / manifestation of this problem is (finally) the recognition regarding scanning in spinal pain and worse outcomes – patients being informed about their degenerative spinal ‘disease’ etc, etc…
    Your thoughts? Any merit? Too utopian?
    Kal
    PS: found an interesting article on ‘disease’:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1299105/

  2. Funny-not-funny that nutrition isn’t anywhere on that list. It really ought to be nutrition (complex topic not understood by mainstream medical establishment) and movement retraining, which would segueway into resistance training down the line after proper bodyweight biomechanics had been relearned.

  3. Kim Bennell says:

    Hi Chris
    Thanks for the post. No we didnt ask about which treatments patients thought would be beneficial which is a very good point – as you point out, patient expectation of benefit does influence outcomes from treatment … so it is very important that clinicians do reinforce this positive expectation of benefit by educating patients about the evidence that we have.
    A survey of UK physiotherapists did highlight misperceptions about exercise in physios as well with many believing that exercise did not have benefit for people with more advanced disease (Holden et al 2008) … something which is not supported by the evidence. So yes we need to educate clinicians about the benefits of our core treatments … if they dont believe in them, the patients certainly wont.
    Kim

  4. Chris Weiers says:

    Hi Kim, Thanks for the summary of your findings.
    As you identify, we know that weight loss and exercise should be the first course of action in managing hip and knee OA. But do the general population (and clinicians) believe that this is the case as well? Did your survey ask about which treatments patient’s thought would actually be beneficial to the management of their OA? If so, did their belief in treatment match the treatments being actually used? Knowing that both catasrophising beliefs and fear of movement are common in OA and counter productive to participation in exercise, activity and weight-loss (Somers et al., 2009)
    I suspect trust in active therapy is not high in the OA population.

    This would seem important to understand as it would help us determine if we should be targeting the wider population with education focused on informing patients and clinicians of the best conservative treatment for OA or should we be targeting patient compliance with the 4 key treatment areas to facilitate them in maintenance of these management options. (most likely both!)

    Thanks again,
    Chris Weiers

    Somers, T. J., Keefe, F. J., Pells, J. J., Dixon, K. E., Waters, S. J., Riordan, P. A., . . . Rice, J. R. (2009). Pain catastrophizing and pain-related fear in osteoarthritis patients: relationships to pain and disability. J Pain Symptom Manage, 37(5), 863-872. doi: 10.1016/j.jpainsymman.2008.05.009