5 Methods to Manage Osteoarthritis

Osteoarthritis (OA) affects over 250 million people worldwide and is a leading cause of disability. The most commonly affected joints are the knee and hip. Risk factors for the development of OA include previous joint trauma, obesity, older age and female sex. The large cost and burden associated with OA highlights the importance of effective treatments for individuals. The purpose of this blog is to highlight 5 methods to help you, help your patients with OA.

1. Marathon Running

I know what you’re thinking, ‘’Luke, ‘’marathon training’’, are you for real?’’. While I appreciate not all of your patients with OA will be running the London marathon next summer, running in general doesn’t need to be off the cards.

In this 2018 research review by Tom Goom, he included a study where the authors delved into the effects of marathon running on knee OA. 1200 participants who had a diagnosis of knee OA, were divided up into runners and non-runners and monitored over a 10 year period. Participants met the ‘’runner’’ criteria if they engaged in running or jogging frequently for approximately 20 minutes each time. The results showed no subjective or radiological decline in knee OA. In fact, runners reported an improvement in knee pain in comparison to non-runners.

This is an incredibly useful study to reassure those patients with a diagnosis of OA and who are eager to engage in running. We can help to advise patients to continue to run without fear of further damage and that it may actually be beneficial for their pain to continue running.

In another study which was included in this research review by Sandy Hilton, 115 runners had an MRI scan of their knees pre and post the 2017 London marathon. The results showed no significant changes in self-reported knee conditions or injuries with an improvement in subchondral bone marrow edema.

However, there were other findings on the MRI can that did not correlate with any subjective symptoms. You can find more information on this study here.

2. Resistance Exercise

Knee OA is associated with thigh weakness and resistance exercise is commonly used to improve strength and reduce pain. However, it is unknown what intensity of strength training is required in the rehabilitation of OA. The START randomised control trial which was covered in this research review by Todd Hargrove aimed to determine whether high-intensity strength training reduced knee pain and joint compressive forces better than low-intensity strength.

The study included 377 adults with knee pain, radiographic evidence of OA and self-reported disability. Participants were divided into a control group and a high and low intensity exercise group. They performed 3 sessions per week for 18 months with a variety of unilateral lower body, upper body and core exercises. The high intensity group performed one block of exercises at 75% of 1RM progressing to 90% of 1RM over 9 weeks followed by a deload and a second block. A new 1RM was calculated for the second block at 75% progressing to 90% over the second 9 week block.

The low intensity group performed the same pattern but at 30% to 40% 1RM. The third group was an “attention control’’ group that involved social interaction and health education on nutrition, medication and sleep.

You might be surprised that after 18 months, there was no significant difference between the groups. Other evidence supports the use of resistance training at various intensities and of differing programme lengths of 6-24 weeks to improve pain and function. However, this research does not support the idea that increasing strength reduces pain. Does this mean that you shouldn’t incorporate resistance training as an intervention for patients with OA? Not necessarily.

Instead of viewing this as ‘’nothing works’’, we could view this as a potential to adapt a variety of treatment options to the patient’s preference. As highlighted in this research review, the key ingredient to any intervention may be adherence to a plan with guidance, instead of the specific details of the plan. Therefore, if someone wants to start engaging in resistance training, it may well be a good option, but it’s possible that it’s not always essential for every patient with knee OA.

3. Neuromuscular Exercise

Exercise can have an analgesic effect in the short and long term for knee OA. However, it is unclear what exact type of exercise affects pain sensitisation and intensity. Todd Hargrove delved into a study in this research review where the authors aimed to examine the effects of neuromuscular exercise and education with and without strength training on the intensity and pain sensitisation in patients with knee OA.

The study recruited 90 people with knee OA and randomised them into 2 groups. Group one performed neuromuscular exercise and education and group 2 performed neuromuscular exercise, education and strength training. Both groups exercised twice weekly for 12 weeks.

The results indicated that the non-strength group had more improvement in knee pain at rest and during function. The authors concluded that neuromuscular exercise and education, with and without additional strength training is a potent therapy for knee OA. However, strength training had greater improvement in pressure pain threshold and pain tolerance threshold.

It is interesting to ponder why the higher intensity group (i.e. strength training) did not provide the same amount of pain relief compared to the low intensity group (i.e. neuromuscular exercises). One potential reason may be due to the inappropriate dosage of the strength training. This highlights the importance of appropriate exercise prescription and programming for individuals with OA, taking into consideration their previous experience with resistance training.

For more information on the methods and limitations associated with this study you can check out the review here.

4. Platelet-rich Plasma

Plater-rich plasma (PRP) is an autologous blood product containing high levels of growth factors and cytokines that can alter the biological processes implicated in OA pathogenesis. As covered by Anthony Teoli in this research review, PRP is still used clinically despite OA guidelines recommending against PRP because of low quality evidence. The objective of the study included in the review was to evaluate the efficacy of intra-articular PRP injections on symptoms and joint structure in patients with knee OA.

This study included 288 participants with knee OA randomised into 2 groups. One group received 3 PRP injections and the second group received saline injections which was the placebo. The findings suggest no difference between the groups with regards to knee pain or medial tibial cartilage volume at 12 months. Interestingly, both groups reported an improvement in knee pain but were not statistically significant. This study does not support the use of PRP to slow disease progression.

However, this study contradicts other research which did show a benefit of PRP on knee OA symptoms at 6 months. There are multiple limitations to this research which makes recommending PRP difficult. I highly recommend checking out the research review here for more information on these studies.

5. Education

It is undeniable now that exercise is vital for individuals with arthritis. Similarly, education is an essential component that is part of the core treatment approach in the rehabilitation of arthritis. Anthony Teoli included a masterclass article in his research review outlining key treatments and implications for physiotherapy in relation to knee OA. The objective of the article was to outline the most efficacious treatment options for patients with OA by authors that are considered experts in the field.

Although these articles may be prone to bias due to the lack of a systematic search strategy or inclusion/exclusion criteria, there were a number of components outlined in the management of knee OA. This included exercise, weight loss, education and self-management strategies as they have been shown to reduce pain and improve function and quality of life.

The clinical implications of this article should be adapted to the specific needs of the individual with knee OA. Therefore, some of the educational components may not be relevant to everyone, as patients can have varying levels of understanding of what OA is. However, the following checklist can be used as a guide when educating your patients:

• Define OA (in simple terms providing a prognosis)
• Identify and address the patients beliefs and perceptions of OA
• Discuss the importance of lifestyle interventions such as a weight loss (if needed), regular physical activity, nutrition, sleep and stress management
• Education on flare ups
• Explain load management and dosing of physical activity/exercise
• Manage expectations, reassure and motivate

This article did not just focus on education, and to learn about the other components that should be part of the first line treatment of OA (and what passive modalities you might want to avoid) check out the research review here.

Wrapping Up

This blog outlines 5 methods to manage osteoarthritis. This is by no means an exhaustive list. If you want more information on these studies and to learn much more, check out the links above to the research reviews.