Case study
Mrs Jones is a 74-year-old woman with type 2 diabetes, hypertension and stage 3 chronic kidney disease. She has come to see you about her painful knees. She has been experiencing increasing pain for the past five months, such that it is now interfering with her sleep and everyday activities. You diagnosed osteoarthritis (OA) four years ago and she has been managing well since, using topical NSAIDs and occasional paracetamol, having tried co-codamol, which made her feel sick. How would you manage this patient further?
This is a familiar presentation in primary care and most GPs recognise the limits to what we can offer patients requiring medication for OA pain.
Oral NSAIDs are usually not advised, topical agents are modestly effective and paracetamol is often of limited value and not without its safety problems.
The lack of drug options for OA forces us to be more creative in the ways we can help patients to manage their joint pain.
The recent NICE guidelines highlight the wide range of non-drug treatments for OA (see figure 1), from supports, bracing and insoles, through to manual therapy (especially for hip OA) and devices such as tap-turners or washing aids.1
My approach is pragmatic, aiming for a combination of management options which, while the individual effect-size may be small, may have an additive effect. Another guiding principle is that treatments for OA should ideally be simple, effective, cheap and self-administered.2
An important consideration is that when we talk about treating OA, with the exception of joint arthroplasty, we do not mean disease-modifying treatments as such. Instead, the goals of treatment focus more on symptoms, impact on function and quality of life (see box 1).
Core treatments
Central to the NICE recommendations are the core treatments of exercise, weight loss (if overweight), education, advice and access to information. GPs should be expert at advising these to all of our patients with OA and this article will focus on these core treatments.
Effective treatment starts with a positive diagnosis and this can be reached following a clinical assessment and without the need for X-rays in most cases (see box 1).
A positive diagnosis of OA, rather than merely 'a touch of arthritis' or 'a bit of wear and tear', allows patients to access the right information so they can begin to find out about living and coping with their condition.
Weight loss if overweight
Most of the published research in OA is about lower limb OA (hip and knee) and the overwhelming majority within that group concerns knee OA cohorts. So the advice about losing weight, for example, is mainly focused on knee OA, although the NICE guideline group concluded that advice to lose weight was sensible for all OA patients.
Every time we take a step, a force of three to six times our body weight goes through our knees, so the link between weight and load through the knee is clear.3 If you are overweight, reducing your BMI by two units reduces the risk of developing OA of the knee by 50%. For a female patient of average height, this equates to about 5kg weight loss.4
The link between weight loss and improvements in pain in established knee OA is less clear-cut. Weight loss of approximately 5% body weight or at least 6kg leads to noticeable improvement in function, but the direct association with improved pain is not as strong.
However, research shows that a combination of diet and exercise leads to more weight loss, less pain, better function, faster walking speed, further walking distance and better health-related quality of life than diet or exercise alone.5
Exercise is one of the most effective weapons in our arsenal for managing the symptoms of OA, with an effect size similar to oral NSAIDs for knee OA, but without the attendant risks.
GP advice
GPs and the primary care team are ideally placed to advise and monitor response to treatment with exercise, but there are challenges.
When patients with OA first start exercising, they often experience more pain and should be warned of this so they persevere.
Qualitative research has highlighted that patients with OA want to be more active, but are worried about pain. I find that starting a conversation about exercise can trigger a constructive dialogue (see box 2).
The benefits of exercise far outweigh the risks. The main risk is injury, but this can be reduced by advising patients on how they can exercise safely.
The types of exercise that are most beneficial are a mixture of:
- Resistance for strength and joint stability
- Aerobic for endurance, metabolism and mood
- Flexibility for balance, range of motion and co-ordination
Conclusion
All patients with OA should be given advice about the core treatments for the condition. Next time you encounter a patient like Mrs Jones, remember there are many options for her beyond the prescription pad.
- Dr Margham is a GP in east London and lead for primary care, Arthritis Research UK
Resources
- Arthritis Research UK (www.arthritisresearchuk.org) has a wide range of information
- National Arthritis Week 12-19 October; for more information, go to www.nationalarthritisweek.org
References
1. NICE. Osteoarthritis: Care and management in adults. CG177. London, NICE, February 2014.
2. Dunbar A. Synovium, spring 2012, No 35. www.arthritisresearchuk.org
3. Felson DT. Weight and osteoarthritis. J Rheumatol 1995; 43: 7-9.
4. Christensen R, Bliddal H. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta- analysis. Ann Rheum Dis 2007; 66(4): 433-9.
5. Messler SP, Mihalko SL, Legault C et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA 2013; 310(12): 1263-73.
