Osteoarthritis is a chronic and progressive condition that mostly affects the hands, spine and joints such as hips, knees and ankles. Osteoarthritis will become one of the most prevalent diseases in populations from high-income countries in the coming decades. It is the most common form of arthritis and the predominant condition leading to knee and hip replacement surgery in Australia.
In this article, we’ll provide a guide about osteoarthritis, how you receive scientific evidence-based care and the treatment options available to you.
Table of Contents
Prevalence of Osteoarthritis in Australia
- 3 in 5 people who have osteoarthritis are female
- People with osteoarthritis were twice as likely to describe their health as ‘poor’, among those aged 45 and over
- There was a 38% rise in the rate of total knee replacements for osteoarthritis from 2005–06 to 2017–18
- 1 in 11 Australians (9.3%) have osteoarthritis, approximately 2.2 million people in 2017–18
Pain Mechanism
It was believed that Osteoarthritis was exclusively a degenerative disease of the cartilage, however, latest evidence has proven that it is a multifactorial entity, involving multiple factors like trauma, mechanical forces, inflammation, biochemical reactions, and metabolic derangements.
Osteoarthritis is a whole joint disease, involving structural alterations in the cartilage, bone, ligaments, capsule, synovium, and muscles. The complex pathogenesis of osteoarthritis involves mechanical, inflammatory, and metabolic factors, which ultimately lead to structural destruction and failure of the joint.
The disease is an active dynamic alteration arising from an imbalance between the repair and destruction of joint tissues, and not a passive degenerative disease or so-called wear-and-tear disease as commonly described.
Hence, when we looking at the targeted pain mechanism to treat the joint-related pain, we should consider the following:
- Nociceptive: Tissue Injury e.g. degenerative disease, osteoarthritis, muscle spasm, inflammation
- Neuropathic: Nerve Injury e.g. nerve dysfunction, post-surgical pain
- Nociplastic: Sensitised Nervous System e.g. complex regional pain syndrome, fibromyalgia
Clinical Presentation
Morning stiffness, reduced range of motion, crepitus, joint instability (buckling or giving-way), swelling, muscle weakness, fatigue, and pain-related psychological distress are also seen frequently in patients with osteoarthritis.
Scientific research has helped us to understand pain is a multidimensional dynamic experience with multiple brain sites activation. From peripheral joint inflammation to neuroplasticity (ie. structural and chemistry changes of the nervous system) leading to emotional distress and behavioural changes.
Factors associated with Osteoarthritis Development
- Age: Result of cumulative exposure to various risk factors and biological age-related changes in the joint structures.
- Heavy work activities: Farming, Construction Industry, High-Impact Sports
- Female Sex, Obesity, Previous Trauma, Genetics
Effects of Persistent Pain
- Biological: Heightened Pain, Cognitive Impairment, Sleep Disturbance, Physical De-Conditioning, Medication Over-Use, Suppression of immunity
- Psychological: Depression, Anxiety, Post-Traumatic Stress, Learned Helplessness, Suicide Risk
- Sociocultural: Social Withdrawal, Dysfunctional Relationships, Isolation, Carer Stress, Vocational Role Interference, Financial Ramifications
Pain Treatment Options
It is no longer acceptable to apply single model fo care to everyone living with osteoarthritis related pain. It is best practice that treatment should be mechanism-based, symptom-based and disease-based. No two patients are alike, why should the treatment follow a strict algorithm? Treatment plans should be patient-centred with biopsychosocial strategy, with personalised approach in a stepped-care model.
The goal of the treatment is to promote resilience, healing, prevent and reduce pain chronification.
Common Treatment Options include (but not limited to):
- Patient Education
- Pharmacotherapy
- Physical Activities
- Cognitive Modification
- Sociological Support
- Procedural Interventions
Pain Education
“Educational Interventions that aim to change one’s understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself” – Explaining Pain
Education is a powerful tool to help you to understand information about the different treatment approaches, information about the disease, about the pathophysiology, and about the diagnostic imaging.
Physical Activities
Exercise therapy is particularly helpful in decreasing pain and improving joint motion. Research shows that a comprehensive programme tailored to individual needs is recommended. No one exercise programme is more superior or beneficial.
E.g. Low-Level Aerobic Exercise For Fibromyalgia, Strength-Training For Back Pain with Deconditioning, Flexibility Training For Arthritis, Balance Training For Weakness Or Risk of Falls
The benefits of exercises include Improve Sleep, Weight Loss, Endorphine Secretion, Reverse Deconditioning, Functional Gain.
The Arthritis, Diet and Activity Promotion and Intensive Diet and Exercise for Arthritis trials showed that the combination of dietary weight management and exercise yield better effects on pain and function.
Yoga, Tai Chi, Acupuncture, Pilates, Hydrotherapy have mixed evidence with short term pain and disability reduction.
Controversy in the guidelines remains about the use of knee braces and heel wedges, intra-articular hyaluronans, and glucosamine or chondroitin are typically not recommended.
Cognitive Modification
Cognitive Behavioural Therapy (CBT) is the most common psychological intervention. It consists of cognitive appraisal, restructuring beliefs, behavioural activation, problem solving and motivation. It helps people living with osteoarthritis pain to conquer fears of moving and emphasise on exacerbation management.
Pain Medications
The most often recommended in the guidelines include paracetamol and anti-inflammatories. Recent research from UNSW demonstrated paracetamol has no benefit in pain reduction. Topical or oral anti-inflammatories were shown to be effective for pain relief and for function.
Nerve medications have established efficacy for knee osteoarthritis pain, which result in pain reduction and improve function. The mechanism is thought to be enhancing the descending modulatory systems (ie. the calming system from our brain).
Regarding opioids use, the small gain weighted against the side-effects, and the risk of addiction and overdosage, has led to an overall discouragement of prescribing these products to patients with osteoarthritis. If pain is severe and not responding to the conventional management, cautious selection of safer opioids with clear goals are essential.
Procedural Interventions
Depending on the symptoms, mechanism and underlying pathology, procedural interventions could be very beneficial to facilitate functional gain. These include:
Joint-block with steroid injection: better outcome to people who show signs of joint inflammation.
Nerve-block with Radiofrequency Treatment: efficacy could last beyond 1 year especially those with higher pre-procedural pain scores and low opioids use.
Neuromodulation: when there is refractory pain management from above procedures
Surgical Options
Joint replacement surgery is a clinically relevant and cost-effective treatment for end-stage osteoarthritis, when the patients are more severely affected functional status. Most improvement will be made in patients with complete joint space loss and evident bone attrition.
Up to 25% of patients presenting for total joint replacement continue to complain of pain and disability 1 year after well performed surgery.
Arthroscopic partial meniscectomy still has a role in people with clear evidence of mechanical knee locking (objectively unable to fully extend the knee). However, meniscectomy (partial or full) can increase the speed of progression of osteoarthritis.
Resources
- Australian Institute of Health and Welfare
- Cohen, S. P., Vase, L., & Hooten, W. M. (2021). Chronic pain: an update on burden, best practices, and new advances. The Lancet, 397(10289), 2082-2097.
- Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019;393(10182):1745-1759.
- Mora JC, Przkora R, Cruz-Almeida Y. Knee osteoarthritis: pathophysiology and current treatment modalities. J Pain Res. 2018;11:2189-2196. Published 2018 Oct 5. doi:10.2147/JPR.S154002
- Hunter DJ, McDougall JJ, Keefe FJ. The symptoms of osteoarthritis and the genesis of pain. Med Clin North Am 2009; 93: 83–100.
- Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Rheum Dis Clin North Am 2008; 34: 515–29.
- Ezzat AM, Li LC. Occupational physical loading tasks and knee osteoarthritis: a review of the evidence. Physiother Can 2014;
66: 91–107. - Moseley, G. Lorimer, and David S. Butler. “Fifteen years of explaining pain: the past, present, and future.” The Journal of Pain 16.9 (2015): 807-813.
- Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;1(1):CD011279. Published 2017 Jan 14.
- Williams ACC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020;8(8):CD007407. Published 2020 Aug 12.
- Higashi H, Barendregt JJ. Cost-effectiveness of total hip and knee replacements for the Australian population with osteoarthritis: discrete-event simulation model. PLoS One 2011; 6: e25403.
- Wylde V, Hewlett S, Learmonth ID, Dieppe P. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain 2011; 152: 566–72.
- Roemer FW, Kwoh CK, Hannon MJ, et al. Partial meniscectomy is associated with increased risk of incident radiographic osteoarthritis and worsening cartilage damage in the following year. Eur Radiol 2017; 27: 404–13.
- Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the US bone and joint initiative. Semin Arthritis Rheum 2014; 43: 701–12.
Action Points
Osteoarthritis, as a slowly progressive disease with irreversible structural change and in which chronic pain phenotypes can develop, needs early proactive management. Your treatment plans should be tailored to your needs with biopsychosocial strategy.
Dr Chow Chow provides remarkable collaborative system with Sydney top leading experts, this includes physical therapist trained in GLAD programme, pain psychologist, dietitian for healthy eating habits, Orthopaedic Surgeons specialising in Shoulders, Knees, Spine, Feet and Ankles.
Have any questions about how to manage your osteoarthritis-related pain? Contact email info@drchowchow.com
