Hello, I’m Norman Swan. Welcome to this program on the new guidelines for the nonsurgical management of hip and knee osteoarthritis. It’s a timely program, as we’re broadcasting during Arthritis Awareness Week. Arthritis, as you know, is a major cause of disability and chronic pain. There’s around 100 different forms of arthritis, and osteoarthritis is the most common. This program is the third in a series of four on the musculoskeletal guidelines that have been developed by the Royal Australian College of GPs and approved by the NH and MRC. This program will cover the diagnosis of osteoarthritis.
And discuss recommended nonpharmacological and pharmacological interventions in a multidisciplinary primary healthcare setting. As always, you’ll find a number of resources available on the Rural Health Education Foundation’s website Let’s meet our panel. Geoff McColl is a rheumatologist and professor of Medical Education and Training at the University of Melbourne. Welcome, Geoff. Thank you, Norman. Geoff is the current president of the Australian Rheumatology Association and was part of the working party developing this guideline. Rana Hinman is a physiotherapist and senior lecturer in the University of Melbourne School of Health Sciences. Welcome, Rana.
Rana has particular expertise in evaluating conservative treatments for osteoarthritis, and was also a member of the working party. Michael Yelland is a general practitioner and associate professor of Primary Health Care at Griffith University in Queensland. Welcome, Michael. His teaching and research interests focus on evidencebased diagnosis and the treatment of musculoskeletal pain. And David Ng, who’s a pharmacist and director of the South Australian and Northern Territory Branch of the Pharmaceutical Society of Australia. Welcome, David. Thank you, Norman. From the home of fish oil. That’s correct.
Hip and Knee Osteoarthritis Guideline for Nonsurgical Management
We’ll talk about fish oil later to see whether or not it’s the magic panacea for osteoarthritis. Many myths about osteoarthritis, Geoffrey There are many myths, Norman. Probably the best place to start is that this is an illness that you acquire as you grow old that you can do nothing about. You’re just going to creak your way to the wall at the bottom of the garden. Absolutely. There’s a certain acceptance that this is the way it will be. NORMAN Are you telling me it’s reversible The pathological process is not reversible,.
But the degree to which your function and pain is affected is reversible. If you work appropriately with the health professionals we have, you can improve your quality of life and perhaps avoid major things like total knee and hip replacements. You can slow it significantly You can alter the natural history by affecting things like your weight, improving muscle strength around it and possibly taking a good look at your health overall. What about physiotherapy from that perspective, myths and misconceptions Most people think there’s no cure well, we know there is no cure.
But that it’s an inevitable process that leads to joint replacement. That’s not the case. Only about a third of people will show progression over time. Michael, what do your patients tell you Patients place too much emphasis on Xray findings. They’ve been led to believe there’s a tight link between Xray findings and pain and disability. While there’s a loose correlation, it’s only a loose one. NORMAN You’ll see somebody with a terrible joint who’s not got much pain Exactly right. Do you find people get scared easily They certainly can, and we want to avoid that.
You talk a lot about the language a GP might use, or even nonverbal language, which might make things worse. We’re dealing with a condition called degenerative, and people think that’s irreversible. As Geoff said, you can do something about it. We don’t want to send the wrong messages about this is a downward spiral. You don’t want to look at the Xray and go, ‘Oh, my God!’ That’s right. What about from the pharmacy point of view The pharmacy is one of the first points of contact for consumers seeking advice about what works and what doesn’t.
In the management of osteoarthritis. We’ll talk about pharmacological options and the level of evidence for more traditional and complimentary options that consumers come in seeking. To have osteoarthritis is to be a consumer of glucosamine, is it not Possibly, and I’m sure we’ll cover that. Is there a single Australian with osteoarthritis who’s not on glucosamine Possibly not. GEOFF The krill stocks of the world are being depleted. NORMAN Going into people’s joints. Is there any evidence that glucosamine makes the slightest bit of difference There’s probably conflicting evidence about whether glucosamine does have an effect in osteoarthritis.
There are some studies which suggest there is marginal evidence. Whether that translates into clinical benefit is something else that needs to be debated. NORMAN It’s only glucosamine sulfate there’s evidence for. Correct. There are two salts hydrochloride salt and sulfate salt. Studies which demonstrate a positive result are those using sulfate salt. Yet on your pharmacy shelves, no doubt, you’ve still got both. There may be. NORMAN May be Sulfate salt is available on the RPBS. I interviewed a rheumatology researcher in the United States who had evidence that glucosamine increases the risk of type2 diabetes.
Is that just a oneoff Those were related to high doses of glucosamine. That can be an issue in patients who have poor glucose tolerance. That’s something that GPs and pharmacists need to bear in mind, particularly patients who are using high doses of glucosamine in the management of osteoarthritis. So gentle scepticism, but if you want to take a reasonable dose, you won’t do much harm I think that’s correct. People go to drugs like glucosamine and chondroitin as the first place. They’ve got a problem, they want to do something themselves.
And so this is the easiest place to go. Across the back fence, Mrs Smith says, ‘I’ve been taking this and it works.’ That’s often how it starts. As health professionals, we need to gently unpack that for them. They’ll be on it when they arrive. We then have this opportunity to say, ‘Do you really think it helps Perhaps you could stop it and see if you get worse.’ Do you often find as a rheumatologist you get referrals for people where it’s misdiagnosed in one way or the other.
Either underdiagnosed or overdiagnosed There are a few common mimics of osteoarthritis of the knee and hip which we need to consider. Probably orthopaedic surgeons see more of this than rheumatologists. NORMAN ‘Cause they’ve chopped it out and can have a look at it Correct. They love this stuff. There’s also that view that osteoarthritis orthopaedic surgeon rather than osteoarthritis let’s do something more generally. NORMAN What’s the most common confusion There are a number of them but probably the commonest is radiating pain from the back, from the facet joints or discs.
Or other structures giving pain in the lateral thigh or the groin. The Xray might show a bit of osteoarthritis, and you think, that’s what it is. In reality, it’s something else. The other thing is hip osteoarthritis being felt in the knee. They swear black and blue that the knee is the problem, then when you examine them ’cause we always examine the joint above and below the affected joint. NORMAN Of course we do. You do it, don’t you And pharmacists do it. You in fact reproduce the pain by examining the hip.
There are things to consider when somebody comes in with a single joint affected by a process that you think is osteoarthritis. Given that we used to think rheumatoid arthritis was a disease of younger people, but it’s a disease of older people, to what extent are the inflammatory arthropathies confused for osteo They can be, but the nature of the history is key. If we’re thinking of an inflammatory arthritis, the onset will be probably over a shorter period of time. There will be greater softtissue swelling. NORMAN And more bilateral. It may be bilateral.
And they may have other joints involved. There can be confusion in the beginning, but as time goes on, it becomes clear. What do we know about the causes Because it’s not necessarily grinding your joints to dust by jogging every morning, I hope. Jogging might still be a good thing, overall, for cartilage. There are a variety of modifiable and nonmodifiable risk factors for osteoarthritis. The nonmodifiable things are, as we grow older, and as far as I know we can’t modify ageing yet. NORMAN Speak for yourself. The telomere is out there.
NORMAN Winding down. Gender, depending on the joint. Again, not a modifiable thing to any great extent. NORMAN Why are women more prone to osteo than men Some of it may be genetically determined. We know for other forms of osteoarthritis Heberden’s nodes in the fingers, that appears to be far more related to female onset. In the knee, bilateral knee osteoarthritis is more common in women. That may be related to obesity, but it may also be related to a genetic thing. There’s theories about venous congestion, aren’t there, Michael.
Yes. This comes up with people who advocate glucosamine, which is supposed to be good for venous congestion. You can develop microthrombi in the ends of bones, which increases pressure within the veins. That’s how you can attribute nighttime pain to osteoarthritis. What does this guideline tell us that we didn’t know already Probably not a lot more from other guidelines. What it does is capture the more recent evidence and gives us a clear picture of where we’ve got a lot of research and where we don’t. It also gives us an idea of where general consistency is.
Around different treatment interventions. Essentially, what the guideline does tell us is that there are a range of nonpharmacological and pharmacological options available for people with OA of the hip or knee, and that we should be using nonpharmacological strategies prior to pharmacological strategies, and ultimately a combination of the two. Tasmanian research has contradicted the notion that you give up walking and running or what have you when you’ve got osteoarthritis, because the people that keep doing it seem to do better. That’s right. It should be the opposite. People should be exercising.
Exercise is one of the cornerstones of nonpharmacological treatment for OA. There are a lot of benefits to be gained from exercising. To what extent are the risk factors shared with other conditions and maybe that it could be a vascular problem or other problems that increase ageing, like smoking, diet Is there any relationship there Probably the biggest relationship is obesity, one of the biggest problems now the increasing prevalence of obesity placing an enormous load particularly on the weightbearing joints of the lower limb. That’s one of the greatest risk factors.
People who are obese are 2.5 times more likely to have OA of their lowerlimb joints than someone of normal weight. And when they lose weight Have there been intervention studies looking at the effect on osteoarthritis Yep, there are good studies to show that losing weight is beneficial. Data shows that weight loss of about 5 is what’s needed to get significant benefits in terms of pain reduction and improved physical function. David, you must see it in your clients. The impact on their lives must be enormous. Absolutely. Most of the regulars in community pharmacy are elderly,.
Where mobility is an issue. They rely on being able to get out to do daily activities. Limitation of function through osteoarthritis or the pain in mobility that comes with it does affect their ability to carry out daily activities. To what extent, Geoff, are we talking about a clinical diagnosis as opposed to firing off an Xray or even an MRI scan NORMAN Which will no doubt please Mr Rudd immensely. We could make enormous savings in the musculoskeletal area just by banning a few key investigations highcost, highvolume things like CT scans, MRIs and so on.
In musculoskeletal disease, the most important thing is a good history and a good examination, thinking about the functional problems the patient has brought with them, then the strategic use of investigations. That may involve an Xray to confirm the diagnosis, but it may not mean much past that. Blood tests are not necessarily helpful in osteoarthritis. Good history, good examination, thoughtful diagnostic reasoning, and you’re probably 90 there. We all know people who have needed hip replacements in their 50s early in life. What’s going on with them Do we know.
Yes. We don’t know everything, but we certainly know that with hips in particular, prior trauma. Trauma probably prior to 30 years of age football and sportingrelated trauma may well be a feature. There may be genetic elements as well, particularly acetabular dysplasia rather than having a nice, firm cup for the hip to sit in, it’s shallower. This seems to increase the risk of degenerative arthritis later. There are a number of factors. I don’t know if we can explain all of them. If it’s unilateral, you’d think of trauma.
Bilateral, you’d think dysplasia. Some paediatrician might have missed a subluxable hip. Ortolani’s test. I’d almost forgotten about that. Let’s take a look at our first case study, Ruby, a 71yearold woman. Her husband is still alive. She’s got two adult children. She presents to your surgery, Michael, with pain and stiffness in the right knee, made worse when she’s active. She gets aching at night. She describes similar but milder symptoms in the left knee. She finds it hard to do housework, and isn’t getting out as much as she used to.
She smokes, has a couple of drinks a week. She’s been to David’s pharmacy and got her glucosamine, but gets it from the supermarket sometimes ’cause it’s cheaper. What do you reckon on Ruby, Michael With the management of Ruby NORMAN Or indeed the diagnosis. She might have glucosamine overdose. We need to make sure she’s actually got osteoarthritis. Based on that story, she probably does. One we’ve sorted that through. Not so quickly, Dr Yelland. Are you going to make a clinical diagnosis, or are you going to keep your radiological colleagues.
In the manner to which they’ve become accustomed There is some role for initial investigations, partly to exclude things, really, rather than to make an active diagnosis of osteoarthritis. Occasionally you’re going to miss the odd tumour. Hopefully you’ll pick that up by taking a better history than what’s been provided here, for example, has she had cancer in the past Is she losing weight Redflag questions. She’d love to lose weight, but she hasn’t been. You succumb, Dr Yelland, and do an Xray. And here’s what you find. Let’s have a look.
MICHAEL OK. NORMAN You’re in a country town, no radiologist. You’re reporting your own Xrays, thanks very much. MICHAEL She’s got markedly reduced joint space in the medial compartment of the knee. There’s some osteophytes there, and she’s got sclerosis of the joint surfaces. The lateral side is not so affected. So the findings are consistent with moderately severe osteoarthritis of the knee. Any advantage to weightbearing Xrays as opposed to having them lying down Much better to go with a weightbearing Xray. Lying down, you can be deceived. The joint space may not appear as narrowed as it really is.
In a weightbearing position, so you get a much truer representation with a weightbearing film. Most tables can cope with the weight bearing The other thing that’s beneficial with the weightbearing film is that it can give you an idea of the static alignment of the knee, and alignment of the knee will also indicate load. A knee that’s got more alignment in a varus direction will be placing more load over the medial compartment and might be at risk of undergoing progression at a faster rate. You wouldn’t get that information from a lyingdown Xray.
If you were tempted to do other investigations on this woman, you might get the shock of your life, because according to a recent paper in The New England Journal Of Medicine, a large number of these people will have meaningless tears of their menisci. That’s right. There are real problems with that. We’re starting with the notion that we’ve made a diagnosis, an Xray we’re comfortable with, a clinical scenario. The MRI then just adds uncertainty. You see things that might be surgically remediable. You then move to the next step.
NORMAN Then you really screw up her knee. That’s right. Does arthroscopy of an osteoarthritic knee. That’s got to be Michael’s first thing. You’re going to send her for an arthroscopy and a lavage. No way. Just in case you’re not sure about this, there is zero evidence for arthroscopy and lavage from two randomised control trials, despite the fact that no doubt an orthopaedic surgeon near you is still doing them. Absolutely right. The problem is that the impact of studies, now separated over five or six years the most recent is the Canadian study.
Behaviour in those jurisdictions, Canada and the US and Australia, is not odd. We’re doing about as many arthroscopies in 50yearolds and 60yearolds as we were doing ten years ago. I think that is concerning. David, this lady, Ruby, will have been to you before she comes to her GP because she’s been buying stuff over the counter to help her out. What do statistics tell us about what people are using before they see their GP, what they’re getting from the pharmacy and what they should be getting I haven’t looked at the most recent statistics.
On overthecounter medication usage, but simple analgesics and most of the medications we’re discussing are available over the counter. Things like paracetamol, antiinflammatory drugs, glucosamine, which we mentioned. Most of these are available either in pharmacies or supermarkets. Most patients, before they come to us or their GP, would have at least tried something prior to seeking advice from a primary healthcare provider. Let’s do it now with the medications. There have been randomised trials which suggest very little difference between paracetamol and nonsteroidal antiinflammatory drugs. What is the step up, if any, when you move to a nonsteroidal.
In what’s largely a noninflammatory condition Regular paracetamol is the standard, or firstline management. Antiinflammatory drugs may be helpful. Some studies suggest there may be additional benefit from adding in a nonsteroidal antiinflammatory agent. NORMAN Adding in rather than replacing Correct. And using paracetamol as an antiinflammatory sparing agent and minimising their use. If you are going to use an antiinflammatory agent, using something shorter acting. NORMAN Such as Ibuprofen or diclofenac would be suitable alternatives for antiinflammatory agents. Bear in mind they do have side effects. Remind us of the contraindications to nonsteroidals.
Some contraindications and relative contraindications to antiinflammatory drugs include a history of peptic ulceration. Patients with hypertension and heart failure require monitoring and followup to ensure that their conditions are not exacerbated by the addition of antiinflammatory agents. Patients with renal impairment are at risk of acute renal impairment from the addition of antiinflammatory agents, particularly if they’re also on ACE inhibitors or diuretic therapy. What do you do for the patient who really shouldn’t be given a nonsteroidal Panadol’s not doing enough. Where to go next Patients who are in that situation should be managed by their GP,.
If not a rheumatologist. If they’re being managed under a multidisciplinary team and undergoing nonpharmacological options and have maximised their therapy, the next step up for patients is opioid therapy. It’s an option. But the side effects from opioids far outweigh the benefits. There is a place for opioid therapy, particularly in patients with moderate to severe osteoarthritis and severe, hardtocontrol pain, or if they’re awaiting surgery for hip or knee replacement. Certainly for shortterm use. Patients who are affected by mobility or osteoarthritis are at increased risk of falls. Those are things that need to be considered in those patients.
This is a program about the nonpharmacological treatment, which the guidelines suggest that’s what you start with, and you have to move on from there. Bear that in mind. We’ll double back to the nonpharmacological treatment. I’ve fallen into the usual trap, but we’ll come back to that. Maybe a script book. On the side, you could buy. Here’s your script. To what extent do you have to do other assessments on someone like Ruby in terms of fall risk, nutritional assessment, that sort of thing, before you move on with her.
These are all essential for nonpharmacological management of osteoarthritis. As you say, assessing fall risk because of the terrible consequences of falls, particularly in the elderly. The big issue of weight loss, and assessing their motivation to lose weight is another big thing. NORMAN Ruby’s not that fat. She smokes, and she’s probably a bit thin, but yeah. Does stopping smoking make any difference to osteo It affects just about everything else, but I don’t believe there’s a lot of evidence that stopping smoking makes a difference to arthritis. With medical students, the thing you ask them is,.
What are the things that smoking doesn’t make worse ‘Cause it’s a shorter list. Osteoarthritis is one, Parkinson’s disease and Crohn’s disease, ulcerative colitis. A small number. For totally different reasons, you would talk about cessation, but not because you would believe it would make the pain better. It might make the exercise easier. Let’s go through the nonpharmacological interventions that are proven in osteoarthritis of the knee. Exercise is one, a range of exercise. Landbased exercise, waterbased exercise, tai chi. One question I want to ask while we’re on medications,.
I saw a paper that suggested that nonsteroidals make osteoarthritis worse. There was a trial done in the late 1980s, early 1990s that showed that indomethacin made hip osteoarthritis progress faster. The concern was, did we make the pain less, so they did more and progressed, or whether there was a direct effect. There was some evidence for the routinely used nonsteroidals. Now there’s no evidence of progression. Sorry to interrupt you, Rana. Isn’t gravitybased exercise better than swimming There’s no evidence to suggest that one form of exercise is better than another.
We’ve basically got two classes of exercise aerobic exercise, things such as walking, cycling, swimming. Or you’ve got resistance training strengthening your muscles groups. Both of those classes will impart benefits. NORMAN You want to build up your quads Quads is a key muscle in the lower limb. It’s such a key muscle with most functional activities, and a major contributor to disability in arthritis and pain. Quadriceps is a key muscle. The hip muscles as well, obviously with hip arthritis, but benefits for people with knee OA if they undergo hipstrengthening training.
The patient says, ‘What do I do to strengthen it Do I have to go to the gym, one of those machines’ What are tips for exercises to strengthen your quads There’s a number of ways. It can be done simply in the home. You can use gravity and body weight to strengthen muscles. You can use lowkey equipment in the home such as cuff weights or resistance bands such as TheraBand. Or you can go to something more hightech, such as the gym, and use equipment and be supervised. It’s as simple as sitting in a chair.
And straightening your leg against resistance Exactly. You can put a weight around the ankle, use body weight doing stepups or chair rises in and out of the chair. They’re some of the most important exercises, particularly if the patient is having difficulty with those functional tasks and it’s not just pain. NORMAN You’re getting better at the activities of daily living. The pain benefit and improvement in function. What about stairs Are stair exercises good Yeah, they’re great. They’re demanding exercise for the muscles of the lower limb and a good way of strengthening the lower limb.
What about reps and how often you should do it What are those recommendations If you’re trying to get a change in muscle strength, you’re looking at six to eight weeks of exercise before you’ll see a strength gain. You’re looking at probably three to four times a week. The more people exercise, the better the benefit will be. The key is maximising adherence. If you prescribe an exercise program to a patient, and say, ‘I want you to do ten exercises six days a week,’ the patient might do it for a week, then their compliance drops off.
It’s finding the balance of giving the patient a regime that will give them a benefit, but not be too much of a burden and cause them to stop exercising, in which case any benefits gained will soon be lost. Lots of questions coming in. One for you, Rana, from Meredyth Bell in the Tamwell Pharmacy in New South Wales ‘Are there exercises you can suggest for a 130kg male who was 140kg’ I don’t remember him from The Biggest Loser but perhaps he was. ‘Besides walking, resistance bands and weights.
Lymphoedema restricts his use of the hydrotherapy pool.’ A challenge. It is a challenging case. As I’ve said, you’ve basically got two classes of exercise. Amongst your aerobic options, you’ll want to choose something lowimpact to minimise the load on the joint. Of your lowimpact aerobic options, swimming is obviously out. You’ve put walking as an option. The only other one to consider would be cycling, would be a good option. Amongst the resistance training, you’re talking about strengthening muscle groups. The idea is to pick your key muscles that are weak.
Or limited in particular functional activities. Typically, we’ll focus on quadriceps, hamstrings and probably the hip abductor and extensors. You have got options there with cuff weights and TheraBand, but if they’re not viable, what would need to be considered is changing body positions, so using gravity or body weight using functional tasks that have the added advantage of improving function. What colour band do you start with Generally, you start with the easiest, with a graded exercise program, and assess how the patient is going. With coloured bands, lighter colours are lighter resistance, typically yellow.
NORMAN You don’t start as a black belt You wouldn’t go with black to start with. A question here from Chevron Island, John West, who asks about the frequency of exercise. Wanting to pin you down on strengthening exercises. For strengthening NORMAN The number of reps. I’m told that when you’re doing strengthening with supervision, they would find out what your maximum is, then come down 25, then do that, which is harder with steps and things. But then 13 reps 5 times twice a day. What’s the story here When someone is starting an initial program from a weakened level,.
You’d be looking at an intensive program for 8 to 12 weeks. That’s what most research studies have done. You’d be looking at exercising four to five days a week, once a day for strengthening. NORMAN How many reps of each exercise 2 to 3 sets of 10 to 15 reps. That’s a rough rule of thumb, and it shouldn’t be just applied out. In order to be effective, you need to supervise the patient the first time with their dosage and the repetitions and see that it’s challenging enough. That might not be challenge enough, depending on the exercise.
It won’t be beneficial if either the exercise is pitched too low or they’re too challenging and you flare the patient up. A question from Marisa Pilla in Queensland. We haven’t heard from Marisa for a few weeks. Welcome back to the program, Marisa. Just pinning you down on what the trials and Cochrane Reviews are saying about glucosamine. They’re really saying that it has, if anything, a very small effect, but most likely has no effect. Another question is the extent of the differential between paracetamol and nonsteroidals, and whether or not you should giving regular doses rather than PRN.
For paracetamol Eitheror. There is an advantage of nonsteroidal antiinflammatories over paracetamol, whether added or compared. The issue is risk benefit. You would always try patients on paracetamol, escalate the dose to the full 4g, then if that was insufficient, you would then decide, depending on their risk factor, to go to a nonsteroidal antiinflammatory. This is the importance of talking to the patient and determining what the problem is. You may use a shortacting nonsteroidal. Less risk. What they really want to do is to go for a walk or play golf or whatever.
They don’t need it the rest of the time. They can use paracetamol. It’s matching with it. There is no doubt the nonsteroidal works better, but the risks are higher. Rana, a question from Queensland asking, is there a website for country doctors where you don’t necessarily have allied health help to explain how hydrotherapy should be done, a place you can go to find that out Your practice nurse might want to teach people how to do it. Yeah. NORMAN You’re keeping this as arcane information. It’s really something that is.
NORMAN I can feel a YouTube coming on. There’s no one spot. There are a number of health professionals that can advise on exercise. Is it just walking in the pool against resistance Is that enough There’s good research that shows, not so much walking in the pool, but showing that landbased walking programs give good beneficial effects. They can be of a similar effect size as we’re talking about with paracetamol and NSAIDs. Chris Barnett, a physiotherapist in New South Wales wanting more elucidation on our toing and froing on the randomised control trials on arthroscopy, debridement and lavage.
To the extent of the placebo response. It’s considerable, isn’t it Enormous. There’s no question that taking someone to theatre, anaesthetising them, putting three holes in their knee, then telling them they’ll be better by an authoritative, generally male orthopaedic surgeon has a huge effect. Chris comments that he has a preference for paracetamol because he believes that nonsteroidals cause degeneration of cartilage. There is some evidence with ligamentous damage. There is, of reinjury and so on. Any evidence that early detection of osteoarthritis makes any difference in terms of interrupting the course.
I’m not sure if there’s any clear evidence about that. GEOFF There’s been no trial. It’s an interesting thought. The NH and MRC would be interested. David, before we go on to our second case study, Ruby fancies taking a bit of fish oil. She’s heard about how all you in South Australia consume is fish oil. Is there evidence for osteoarthritis There’s a bit of evidence for rheumatoid, as we discovered in our last program in the series, but what about osteoarthritis We put fish oil in our water in Adelaide. It’s good for everything.
NORMAN You need it in your water. As far as I’m aware, there’s no current evidence that fish oil is beneficial in osteoarthritis. There’s no studies that have been done to demonstrate it that I’m aware of. NORMAN Geoff I think there probably is some small studies. Certainly it stops you having sudden death on your exercise. The ones I can bring to memory immediately is combination with nonsteroidal antiinflammatories in an additional benefit. But there are so many other health benefits to fish oils, if appropriately provided and it’s the right kind of fish oil,.
The riskbenefit looks better for that than what we were talking about. It’s a lot more than just a couple of capsules a day. Someone said 15mL of actual oil. That’s correct. You’d need to buy concentrated oil and take about 20mL of the proprietary product. NORMAN Swallowed down with South Australian water. With South Australian Riverland oranges. Certainly the capsules you get is not enough. You’d need about ten capsules. NORMAN So it’s cheaper to buy the oil. Let’s go to our second case study. This is Harry, who’s in his late 50s.
He’s got twin sons aged ten. He’s under pressure, second time around, two families to look after. He comes to you with rightsided groin and lateral thigh pain radiating into his anterior thigh. When you examine him, he’s got tenderness over the greater trochanter on the right hip and reduced hip movement and tender when you try to abduct, internally rotate or extend his hip. He thinks he might have a hernia. He’s a builder, and he’s a bit worried about what you might tell him is going on. Your patient.
OK. We need to clarify the diagnosis. Just because he’s got anterior groin pain doesn’t mean he’s got osteoarthritis. NORMAN He could have a hernia. Of course you can check him for that. He’s also got lateral tenderness, greater trochanter tenderness, which always makes me think about back problems, so I’d certainly be examining his back. If I satisfied myself that wasn’t the cause, then perhaps he does have osteoarthritis. We’d need to deal with that question about Xraying him at that stage. He doesn’t believe you, so you send him for an Xray of his hip,.
And here’s what you find. OK. In this Xray, we see degenerative changes in both hips, more so on the right, with erosion of the cartilage. The joint space is very narrowed, and there’s sclerosis above the head of the femur. Some lateral osteophytes as well. He’s got osteoarthritic changes, bilaterally worse on the right. NORMAN What are you going to do for him First of all, we’re going to talk about the condition itself and do some education about it. Which is something we didn’t talk about with Ruby’s case.
There is evidence that knowledge reduces pain. So explain the pain process to him, and that this doesn’t mean he has to stop being active. In fact, we’d encourage him to stay as active as possible, and reassure him that quite a lot can be done about this condition. Take a positive approach. We certainly should avoid firecracker words like degeneration, and. your hips are crumbling. NORMAN Firecracker words. That’s a great term. And the need for surgery in the very near future and so on. We don’t wish to alarm him.
We wish to empower him to be involved in his management and to do as much as he can get better. What do we know about what you can do nonpharmacologically for osteoarthritis of the hip I thought it was questionable whether exercise makes a difference to progress. The reality is with regards to the hip, we’ve got far, far fewer research studies than we’ve got at the knee. One of the limitations of the current guideline is that the vast majority of the evidence contained within the guideline comes from studies of patients with knee OA.
We’re assuming that it will apply equally and similarly to patients with the hip. Wasn’t there a study of hydrotherapy which showed minimal effect There is one or two studies that show minimal or no effect. However, there’s been a couple of clinical trials that have shown small effects of other forms of exercise around the hip. NORMAN Such as For strengthening, a musclestrengthening program. Give me an idea of what are the pelvic girdle, thigh exercises. There are simple home exercises for hip osteoarthritis in sidelying or prone or supine positions.
Strengthen all of the muscles around the hip. Depending on how weak the patient is, just the weight of the limb against gravity may be enough initially. Lying on your side and raising the leg RANA Will strengthen the hip abductors. You can do bridging exercises to strengthen the extensors. NORMAN When you say bridging Bridging, that’s in supine in a crook position with your knees bent up. Then lift your backside up in the air so you’re extending off the bed. NORMAN Arching up as if somebody’s sticking a pin in your bum.
Exactly that. Then you can progress into standing positions where you’re using TheraBand, or the resistance band is the best way to go. You need to have household furniture positioned appropriately, tying the resistance band around the leg of a table that’s sturdy. You can just imagine dragging the table around the house after you. If it’s not heavy enough. You can exercise the hip in most planes. Is there an equivalent muscle group to the quads in the hip That’s a good question. The answer is, we don’t know. There’s been a real lack of research,.
Particularly into understanding the biomechanical impairments that exist with hip OA. We know know a lot about knee OA that quadricep weakness plays a key role. We can assume that around the hip there’s going to be similar muscle weakness. Theoretical rationale suggests the hip abductors and extensors would be the most beneficial muscles to strengthen. They’re quite key in stabilising the pelvis and in walking. But there’s a lack of research to guide us with interventions. What about core muscles psoas and so on, the planktype exercise. Do they make any difference to the hip.
They will. The further proximally you go up the chain, the more important the core is. What you often see clinically is, patients with hip OA often have a lot of spinal pain. It often goes hand in hand, which can make it tricky to exercise. You’ve got the fine balance of coming up with an exercise program that’s beneficial to the hip but that doesn’t aggravate the lumbar spine, for example. Michael has this conversation with Harry about exercise, and he stops him and says, ‘I’m a builder. I’m up and down stairs and ladders all day.
I don’t stop moving until I get home at night.’ That’s a good point. That’s where education is key. Patients often think, I’m physically active, that’s exercise. There’s a difference between doing physical activity that’s part of the day and doing a specific exercise there to impart a physiological response. But he tells you, ‘I’ve got to be on the site at seven in the morning. When do I do my exercise’ That’s why it’s really important to work with the patient, engage with an appropriately trained health professional to work out what’s going to fit his lifestyle.
If he doesn’t do it, he won’t get benefits from it. To what extent is a buddy important, having somebody there to help you through rather than doing it by yourself Research shows that motivation is one of the reasons why group exercise is effective, particularly at the outset when starting an exercise program. Not only is it motivating and you have the social interaction, but it gives you another reason to attend. Just when you’re thinking, ‘I’ve had a tough day,’ if someone else is going, it can drag you out.
More and more country towns have walking groups, but this is more than a walking group. This has to be systematic. There are various approaches. Ideally, the buddy is even trained and empowered to be involved. We’re social beings, and making things social activities is about adherence. It’s about getting through to that three or fourmonth mark where it becomes a routine. If you can get there, often the sustained factors are better. It’s a behaviour change, and that takes a while. There was a recent metaanalysis of exercise for hip OA,.
Which had about nine studies in it. Eight of the nine were positive, one was negative, the biggest one. In that study, they just did home exercises as opposed to the other eight, where they had supervised exercise. NORMAN So you’ve got to be serious about it. It’s difficult in remote areas to get access to that, but where you can get that health instructor to instruct and motivate people, you’ll do better. They’re about as effective as paracetamol. They had an effect size in these studies about as effective as paracetamol as a pain reliever.
The other option for a remote area to help improve adherence with exercise is to provide patients with either a detailed instruction booklet or audio or tutorial material as well. That can help improve adherence with exercise. We’ve all met Harry. Hundreds of Harrys are out there in rural, remote, metro. And they’re tricky. They don’t come back. They get the diagnosis and disappear. Those early discussions are very important to get him thinking about what this means for him. It will have a huge impact on him whether or not he goes for a hip replacement.
He needs to be engaged in his own health. It might be the first time he’s ever thought about his health. To what extent does this delay or avoid the need for hip arthroplasty ‘Cause he’s going down that road, isn’t he He is. I don’t think we know whether intervention would do more than just delay it. But they’re in hip. In knee, it may be you’ll remove some from the waiting list forever, but with hip, you may just alter the natural history and deliver someone to the surgeon in a much better position.
He says, ‘I haven’t got time for this. Just give me one of those injections in the hip people swear by.’ The cortisone NORMAN I assume that’s what Harry’s talking about. Mix in a little local anaesthetic if you want, even better. Of course. These do have some role for patients who are in a pretty bad way and having an acute flare. There is a role, but there’s a limit to them as well. Generally it’s three per year. The other problem with these is, if they are heading for an operation,.
Injections within three months of surgery may carry an increased risk of infection with surgery. That’s extrapolating from the shoulder studies, I must admit. An infection in a hip replacement is a disaster for the patient and for the surgeon. Any risk that in injecting the hip that you prang the artery to the head of the femur Generally, we would ask the radiologist to perform an injection into the hip. It’s a long way down. It’s not for the fainthearted or the amateur. Let’s go to our third case study, which is a film.
Which follows the story of Alex, referred by his general practitioner to the Bendigo Osteoarthritis Hip and Knee Service. These are really interesting services spreading round the country. Let’s look at the Bendigo experience. To have osteoarthritis, I can tell you is very, very painful. It is not only during the day, when you’re trying to walk around and be mobile. Even at night, when I try to sleep, the pain is constant. I’m here to see Theo. He’s having a look at my knees. Mr Pinkster Yeah. The Osteoarthritis Hip and Knee Service is designed to optimise the management.
Of patients referred for hip and knee osteoarthritis by their GPs. We were aware of the increased waiting list in this category of patient. Following the trial of the project in metropolitan hospitals in Melbourne, we were keen to be the first regional hospital to provide this service. The initial evaluation is a comprehensive assessment. As well as filling in a questionnaire developed for the Osteoarthritis Hip and Knee Service, the questionnaire is resent at regular intervals, and any change, whether it be positive or negative, is noted and acted upon.
When I do the gardening, I find that I have difficulty whippersnipping. I want to collect as much information as I can so I can understand the burden of arthritis on Alex as an individual. After two hours or so, I’m in real pain. What medication do you take for pain Valium. There’s a lot of education about correct use of medications. If we assess that pain is severe and significant, we can let the GPs know that they can give them stronger pain relief. There’s a lot of communication with GPs about that aspect.
You can see on the inside of both the left and right knee, the space between the two bones is a lot narrower. That usually indicates that your cartilage has become thin and your cushioning between the joints has narrowed, so you’re getting more pressure on your bones. It’s a typical feature of osteoarthritis. He is not keen or ready to proceed to knee replacement. They’re still functioning quite well and his symptoms are relatively mild. Plus, there are other contributing factors that haven’t been addressed fully. There is scope for a variety of nonoperative measures.
That may improve his symptoms, keep his function adequate, keep his pain under control and potentially not need to have his knees replaced for a long time. The Osteoarthritis Hip and Knee Service is a multidisciplinary service. We understand that management of osteoarthritis requires professionals and expertise. I’d like to refer you to the physiotherapist and exercise therapist for more strengthening and improving your general fitness and function. I’d like to have the opinions of several professionals to try and optimise every aspect of your care. He put me in contact with James, a physiotherapist.
I’ll do some little movements on the kneecap..who assessed me and tried various exercises and manipulations of the knees. When you were pushing on the knee. I was also put in contact with a dietician to lose some weight, because that has an impact on my condition. One of the things is your alcohol intake. Alcohol has lots of calories. You’re drinking three to four glasses per day. That’s correct. Being overweight significantly increases pain and disability with arthritis and also potentially progresses the condition. In Alex’s case, his body mass index was 37,.
Which puts him well and truly into the obesity range. It’s an important aspect for his care. Just halfway, not too deep. ALEX He also then put me in contact with Matt. He supervises my gym work specifically for the knees, to try and strengthen them or ease some of the tendons so the pain will be less. MATT There’s no increase in swelling ALEX It is a program that is under supervision in the gym work, in the hydrotherapy. Someone will say, progress is fine or, no, we need to change tack and try something different.
We have noted from our review process that probably two thirds, three quarters of our patients deferred from surgery improved health status, with the conservative measures instituted. The group that needed surgery, many of those patients have improved hip and knee questionnaires. It means that when they turn up for surgery, they are fitter and more comfortable and have a better understanding of what is required to recover from their operation and are more likely to have a rapid recovery. The OAHKS service has halved our orthopaedic waiting list for patients to come in to outpatients’, which is amazing in 18 months.
It’s actually taken out those patients that don’t need to go to surgery yet so they’re seen by the physio rather than the surgeon. It decreases those patients that take up surgeons’ time. Surgeons are now seeing more patients, and seeing patients that are likely to need surgery. When I sent out the patientsatisfaction survey, they were raving about how fantastic it was, how people spent time to listen to them and how they were able to walk again and do things. That’s given them that ability to reengage in life.
When you get pain, you can become isolated. When you isolate them, it’s a selfperpetuating problem. To give them options and ways to manage their pain gives them that benefit. I feel it has made a difference. It has only been three months, but some of the pain is less, and I have maintained more mobility than I have in the past. Hopefully this will continue. The idea is to hopefully avoid surgery. I’d like to keep my own knees for as long as possible. Alex in Bendigo. Orthopaedic surgeons, Rana, love these clinics, don’t they.
Because they’re consultantsupervised but physiotherapistled. It really does take the load off the orthopaedic surgeon and ensures the people who see the orthopaedic surgeon are the ones that need to. NORMAN So their hit rate for surgery goes up. Also, people are getting to see physio in a more timely manner rather than waiting three, four, six months down the track after the orthopaedic surgeon has seen them referred. They’re getting their physio and starting exercise programs earlier, which helps to limit some functional decline that can happen with progressive muscle wastage.
Michael, what are the specifics that are different from the city in looking after people with osteoarthritis, the challenges and solutions In rural areas NORMAN Yes. Access to assistance from allied health professionals is one thing, of course. Access to surgical facilities, if they’re needed, for the more severe patients. In the farming community and so on, there’s more manual labour involved, so they’re more demanding. Another risk factor for osteoarthritis is repetitive trauma, repetitive lifting and hard work. NORMAN Geoff I’ve worked in a rural area for the last 15 years,.
And it’s changed enormously. 15 years ago you were pushing uphill to get services and provide things. We’re now seeing services provided, allied health is more available. GPs are empowered and engaged and part of the community. Sometimes I wonder whether we need to emulate what we’re seeing in rural areas in metro. What Indigenousspecific issues for Indigenous communities They might get osteoarthritis earlier and worse than the White community. I’m not sure there’s evidence, but that is a reasonable thing to say. The problems in Indigenous health is, where they are.
Are they in a remote area where they probably won’t have access to those things, relying on sparser services Equally, in metrodwelling Indigenous populations, accessing and remaining engaged in their own care is important. What about rules of thumb for setting up one of these multidisciplinary teams That’s obviously an extensive service they’ve got there in Bendigo, but as long as you’ve got a physio, access to a consultant orthopaedic surgeon and some facility for delivering nonpharmacological interventions, it doesn’t have to be the fancy gym we’ve seen in Bendigo. Patients could be seen by a physio, and even if there’s not regular access,.
A setup with a good homeexercise program and other strategies that might entail selfmanagement would still work. I don’t think we’ve got the answer to our poll question yet, but I’ll ask for your takeaway messages. Then we’ll come back to our last question about access to orthopaedic surgeons. What’s your takeaway message, David My takeaway is that, for osteoarthritis, there’s no cure or diseasemodifying agents for the management of osteoarthritis. Pharmacological options need to supplement or complement nonpharmacological options. Community pharmacists are well placed to provide advice, and there’s a good network of community pharmacies.
In rural and remote Australia. They can help reassure people like Harry and Ruby about the pharmacological options in their management of osteoarthritis. NORMAN Michael My key message about management would hark back to the diagnosis, and reassuring a patient that things can be done. Be careful about those firecracker words degeneration, things are falling apart, you’re heading for hip replacement, et cetera and focus on positives. Be careful with your Xrays and how you explain them to patients. NORMAN Rana My key message would be that exercise is pivotal for all patients.
There’s a form of exercise that suits any patient, no matter how mild or severe. The key to longterm success is coming up with a strategy that maximises adherence. In addition to the wonderful words we’ve heard, osteoarthritis is a symptomatic presentation that can be the beginning of a wider health discussion with your patient. Lock them in to other discussions that are necessary. We hope you enjoyed this program on the new guideline for nonsurgical management of hip and knee osteoarthritis. If you’re interested in obtaining more information about the issues raised,.