Moving past the burden of osteoarthritis
You have most likely heard someone talk about arthritis (more specifically osteoarthritis), or have been told that you have it. Typically someone will usually claim that they can’t do something because of their arthritis, or (inappropriately) be told that they shouldn’t do something because of their arthritis. This could be partially attributed to the outdated and incorrect thinking of osteoarthritis as “wear and tear” which is sadly still being propagated, but we now know that it is NOT caused by wear and tear1,2. So what is osteoarthritis and what should we do about it?
To start, a couple of the signs of osteoarthritis are narrowing of the joint space - this is due to a decrease in cartilage - and some abnormal bone growth1,2. The bone growths are osteophytes and they can make the joints appear and feel a little bumpy. Some things that you might feel with osteoarthritis are joint pain, stiffness in the morning or after sitting for a while, and possibly some limitations in your range of motion1,2. One thing that isn’t seen on an x-ray, however, is something called synovitis, which is inflammation of the lining around the joint1,2. Keep inflammation in your mind as I will be coming back to this point later on.
Now that we know what it is and that the previous belief of wear and tear is wrong, I want to highlight the burden that osteoarthritis has been shown to have, but also educate on how it doesn’t have to have that burden. First, about 30% of people over 45 have signs of osteoarthritis on x-ray; however, only about half of those individuals have symptoms2. Wow, 50% of people have it but it does not affect them! Those numbers are awesome and should be instilling a lot of hope and optimism in anyone who is reading this. To me, this just points out that having osteoarthritis truly does not mean that you will have loss of function and/or pain, but rather that you can overcome it and live without fear or limitations. Along with the symptoms, functional decline, or not being able to do as many things as you used to be able to do, is related to arthritis. When looking at what may be causing the functional decline in this group, it is shown that a decreased amount of regular vigorous physical activity is the strongest risk factor3. Tying things together, the outdated idea that osteoarthritis is wear and tear can contribute to a belief that you are broken and should do less. This belief - and sometimes advice from a practitioner to do less - is actually harmful and wrong, leading to a greater decline in function due to a lack of regular vigorous physical activity. On the other hand, individuals that do participate in regular vigorous physical activity have much less decline in function, and adding it in is estimated to decrease decline over two years by one third3.
This is an easily* modifiable risk factor, and it should be at the forefront of the treatment. The asterisk is there because changing the behaviour and getting people to exercise more is not necessarily easy. For those who have the means, it may be very easy, but for others there are many socioeconomic, cultural, etc. factors at play that can present as barriers. With this being said, if your healthcare practitioner is not doing their best to address these barriers and work with you, then they are not doing their job.
On the subject of treatment and what healthcare practitioners should do, there are a few guidelines that should be used to direct treatment. Some of them are more lenient and conditionally recommend treatments that only have low quality evidence behind them - basically meaning they may or may not help some people, but they do less harm than good - whereas others can be a little bit more strict. In my opinion, the treatments with low quality evidence could potentially be seen as harmful since they can take away time from other treatments that have high quality evidence backing them. Ok, no more wasting your time let’s get into the guidelines. I will be focusing on the OARSI4 and ACR5 guidelines. The strongly recommended treatments from them are exercise and education which promotes self-efficacy, self-management strategies, optimism, and teaches you about osteoarthritis. Bonus, you are getting that education piece just from reading this article! The type of exercise that is preferred is any land-based exercise4,5. This makes it easy to individualise and it should be something that you enjoy and will continue to do. Aquatic exercise can be a good alternative to land based exercise for the short-term4,5,6; however, it is only conditionally recommended as there may be some accessibility considerations.
A common recommendation that you may hear for osteoarthritis is to lose weight. There is some variance on this point, OARSI conditionally recommends this only if you are obese, and ACR strongly recommends this. Yes there are improvements in symptoms seen with weight loss, especially when exercise is a component2,4,5, but just a blanket statement to lose weight is often presented as a means to decrease load on the joints; however, this just perpetuates the outdated and incorrect view of wear and tear again. So, if decreasing your body mass to decrease load isn’t actually the mechanism that helps with the decrease in symptoms, what does? The exercise that you use to help lose weight may be one of the mechanisms2. Also, if you can remember that synovitis is inflammation, losing weight can actually decrease the inflammatory markers which could potentially play a role in the decrease in symptoms2.
To save time from making this a boring complete review of the guidelines4,5, I will leave out many of the conditionally recommended/non-recommended treatments, instead I will focus on the treatments that are non-recommended that are commonly still used. Starting off hot, TENS (transcutaneous electrical nerve stimulation) is not recommended. This is the little pads that get put on you and then some electricity runs through them. Way too many chiros and physios use these, and sadly I have seen these used on osteoarthritis patients first hand. A prominent second place mention is manual therapy! And the honourable mentions are PRP (platelet-rich plasma) injections, glucosamine, and chondroitin. I have personally seen all of these treatments given or recommended to patients, and from scouring social media it seems that they are common treatments. If you are offered these treatments from your healthcare practitioner it is time to walk out of that office and look for someone who is familiar with the guidelines.
Osteoarthritis can be a burden on you, but it doesn’t have to be. With some good education, movement, and optimism you can take back and maintain control over your body. These joint changes don’t dictate what you can and cannot do because your body is adaptable and resilient. As always, it’s time to get out there and move!
*This is an informational resource and not medical advice, please consult your healthcare practitioner for diagnosis, treatment, and guidance.
References
- Man GS, Mologhianu G. Osteoarthritis pathogenesis - a complex process that involves the entire joint. J Med Life. 2014 Mar 15;7(1):37-41. Epub 2014 Mar 25. PMID: 24653755; PMCID: PMC3956093.
- Katz JN, Arant KR, Loeser RF. Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review. JAMA. 2021 Feb 9;325(6):568-578. doi: 10.1001/jama.2020.22171. PMID: 33560326; PMCID: PMC8225295.
- Dunlop DD, Semanik P, Song J, Manheim LM, Shih V, Chang RW. Risk factors for functional decline in older adults with arthritis. Arthritis Rheum. 2005 Apr;52(4):1274-82. doi: 10.1002/art.20968. PMID: 15818691; PMCID: PMC1199524.
- Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ, Espinosa R, Haugen IK, Lin J, Mandl LA, Moilanen E, Nakamura N, Snyder-Mackler L, Trojian T, Underwood M, McAlindon TE. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019 Nov;27(11):1578-1589. doi: 10.1016/j.joca.2019.06.011. Epub 2019 Jul 3. PMID: 31278997
- Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, Gellar K, Harvey WF, Hawker G, Herzig E, Kwoh CK, Nelson AE, Samuels J, Scanzello C, White D, Wise B, Altman RD, DiRenzo D, Fontanarosa J, Giradi G, Ishimori M, Misra D, Shah AA, Shmagel AK, Thoma LM, Turgunbaev M, Turner AS, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). 2020 Feb;72(2):149-162. doi: 10.1002/acr.24131. Epub 2020 Jan 6. Erratum in: Arthritis Care Res (Hoboken). 2021 May;73(5):764. PMID: 31908149.
- Bartels EM, Juhl CB, Christensen R, Hagen KB, Danneskiold-Samsøe B, Dagfinrud H, Lund H. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016 Mar 23;3:CD005523. doi: 10.1002/14651858.CD005523.pub3. PMID: 27007113.
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