06.13.2019
by Julie Maurer
Contributing Writer, MedPage Today

When a patient is diagnosed with osteoarthritis (OA), his or her first instincts might be to reach for their medicine cabinet or wonder if surgery is in their future, but researchers say that early intervention with exercise and education is important.

Canadian researchers have published a study about possible barriers that stop patients from starting non-pharmacological approaches.

“In a systematic review of studies comparing OA quality indicators to community-based clinical practice, pass rates for first-line non-pharmacological approaches (e.g., exercise, education) were, on average, below 40%,” authors Crystal MacKay PhD, MHSc, BScPT, and colleagues wrote.

They note that research has shown that working-age adults with mild-to-moderate osteoarthritis reported limited guidance and support from their healthcare professionals.

“Given the growing awareness of the importance of identifying and initiating treatment in the early phases of OA, it is critical to begin to address this practice gap. Intervening early in the disease has potential to help control OA pain and disability and reduce work loss,” MacKay and colleagues wrote.

The researchers identified enablers of management, including physical therapists’ confidence, beliefs about the consequences of osteoarthritis, and their scope of practice.

“We also identified modifiable factors that can be barriers to management in some situations and can be targeted to improve care: availability and timely access to services in the community (e.g., exercise programmes) and healthcare system (e.g., PTs); healthcare provider factors including time, access to evidence, and physicians’ referrals and messaging to clients; and client engagement in management and beliefs about OA,” the authors wrote.

MacKay and the other researchers added that some patients simply believed that nothing could be done about their symptoms.

“Other clients were reluctant to accept an OA diagnosis, particularly when X-rays do not show changes in the early stages of the disease,” they wrote.

The researchers said that more studies are needed to find ways to optimize timely access to physical therapists and other programs to increase early interventions.

“Addressing these barriers will require a multipronged approach, targeted at both the healthcare system and healthcare providers,” MacKay and colleagues wrote.

Physicians are also exploring the topic of the best non-surgical knee osteoarthritis management in Hong Kong, according to a March 2019 study in the Hong Kong Medical Journal.

“In aging populations, the prevalence of KOA is expected to increase; thus, there is a need for consensus on non-surgical OA management, so as to improve outcomes for patients with OA and to decrease the burden of arthroplasty,” wrote HS Kan and the other authors of the study.

The researchers found that exercise programs for osteoarthritis patients have lowered the need for arthroplasty and are effective for the improvement of pain, physical function, mobility, and quality of life.

“Long-term follow-up of such exercise programmes should be considered to further assess their outcomes,” the authors wrote.

They pointed out programs such as the Osteoarthritis Chronic Care Program in Australia, OsteoArthritis in Sweden, and Good Life with osteoArthritis in Denmark that have been successful in improving patients’ quality of life and mobility.

“An exercise programme helps to decrease the demand for arthroplasty; 11% of knee and 4% of hip OA participants who had been waiting for arthroplasty agreed they no longer needed surgery,” Kan and colleagues wrote.

The duration of these programs is usually about three months, with a 12 month follow up.

The American College of Rheumatology, in a 2012 publication, recommends all patients with symptomatic knee osteoarthritis be enrolled in an exercise program, in accordance with their abilities. These exercises could include aerobics, aquatics, and resistance work.

“Nonpharmacologic modalities conditionally recommended for knee OA included medial wedge insoles for valgus knee OA, subtalar strapped lateral insoles for varus knee OA, medially-directed patellar taping, manual therapy, walking aids, thermal agents, tai chi, self‐management programs, and psychosocial interventions,” Marc C. Hochberg and the other authors of the paper stated.

ACR also recommends patients with knee OA who are overweight should receive counseling from their physician about weight loss.

Rheumatologist Francis Williams, MD, FACR, at Kelsey-Seybold in Houston, Texas, does just that by discussing diet and exercise with OA patients on their first visit.

“Not necessarily formal physical therapy, but at-home exercises. For some, we discuss starting gentle exercises such as water exercise, biking, or a walking program,” Williams told MedPage Today in an e-mail.

He noted that lifestyle changes, including diet and exercise, can be a barrier for patients.

“I counsel them that these steps would help them be in better condition for the long term,” Williams stated.

For patients who need the motivation to start physical therapy, he uses himself as an example.

“I tell them I exercise and lost over 20 pounds and that my knee does not hurt when my weight is down,” Williams stated. “In general, I use formal physical therapy when necessary, However, when patients don’t comply with the prescribed regimen for exercise and weight management, it delays their progress and presents an extra challenge for me to convince them that they need to take more ownership of their health.”