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Managing Arthritis Non-pharmacological approaches to managing arthritis Lyn M March and Judy Stenmark
MJA 2001; 175: S102-S107 → Other articles have cited this article Key Evidence - Exercise and physical therapy (E1) - Hydrotherapy/balneotherapy (E2) - Patient education and self-management programs (E2) - Telephone support (E2) - Weight reduction (E3) - Viscosupplementation (E1) - Glucosamine and chondroitin sulfate (E1) - Omega-3 oils (E2) - Antioxidants (E3) - Transcutaneous electrical nerve stimulation (TENS) (E2) - Herbal therapies — capsaicin, avocado/soybean (E2) - Low level laser therapy (LLLT) - Patellar taping (E2) - Walking stick (E3) - Orthotics, heel-wedges (E2) - References - Further reading - Authors' Details - Register to be notified of new articles by e-mail - Current contents list - More articles on Allied health | ||||||||||||||||||||||
| Key Evidence | |||||||||||||||||||||||
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Aerobic and resistance exercises can reduce pain and improve function and quality of life in osteoarthritis. Exercise is safe and effective in the elderly. (E1 — see below for key to level-of-evidence codes.)
Ettinger WH, Burns R, Messier SP, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis: the Fitness, Arthritis and Seniors Trial (FAST). JAMA 1997; 277: 25-31. Glucosamine and/or chondroitin provide reduction in pain and stiffness in osteoarthritis when compared with placebo and may result in long-term slowing of disease progression. Further long-term trials are needed. (E2)
McAlindon TE, LaValley MP, Gulin JP, Felson DT. Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA 2000; 283: 1469-1475. Patient education and self-management programs, as offered by the Arthritis Foundation of Australia, are cost-effective and may result in reduced pain, improved quality of life, improved exercise compliance and reduced health services utilisation. (E2)
Superio-Cabuslay E, Ward MM, Lorig KR. Patient education interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with nonsteroidal antiinflammatory drug treatment. Arthritis Care Research 1996; 9: 292-301. | |||||||||||||||||||||||
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Rating of the evidence for recommendations | |
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In this article, evidence is graded according to the level-of-evidence classifications endorsed by the National Health and Medical Research Council (NHMRC) in 1995.
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E1 Level I: Evidence obtained from a systematic review of all relevant randomised controlled trials. E2 Level 2: Evidence obtained from at least one properly designed randomised controlled trial. E3 Level 3: Evidence obtained from all well-designed controlled trials without randomisation, well-designed cohort or case-control analytic studies, preferably from more than one centre or research group, or from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence. E4 Level 4: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
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Management of osteoarthritis has focused on symptom modification, predominantly pain relief. It is likely that strategies to repair the "failing" articular cartilage will need to target multiple mechanisms of disease. Despite promising research, to date no drug capable of modifying the structural damage of osteoarthritis has been confirmed in long-term human studies. This is in contrast to rheumatoid arthritis, where several agents prevent bone erosion and joint damage if used early enough in the disease. Numerous non-pharmacological treatments now exist that can reduce the symptoms of arthritis and, in so doing, may improve function.1-5 The myths that "nothing can be done about it" and that "it is just something to be put up with" need to be dispelled. Knowing that osteoarthritis of the knee progresses only very slowly over 10 years in most patients,6 and that most will not need joint replacement surgery, can make a big difference to the patients' outlook. Factors related to disability in arthritis are similar to those related to disease progression.7 Some of these risk factors cannot be modified (eg, genetic predisposition, family history, female sex, age) but others (eg, injury, obesity, quadriceps muscle strength, misalignment, and inflammatory or septic arthritis) are potentially modifiable or preventable. For the most part, addressing these factors involves non-pharmacological strategies. Disability in arthritis is the result of the combination of three main factors: the arthritis itself; inactivity; and the ageing process. A vicious cycle develops whereby inactivity over long periods may be the major cause of disability, compounded by the progress of arthritis. The tendency in our society to become less active with age is part of the problem, as is the common belief that osteoarthritis is simply a "wear and tear" disease made worse by exercise and movement. Prolonged inactivity can lead to proteoglycan loss from articular cartilage and will thus enhance cartilage breakdown. Muscle weakness and wasting will also ensue. Quadriceps weakness is a well-documented risk factor for the progression of disability and radiological damage in osteoarthritis of the knee. Recent research has demonstrated the beneficial effect of movement and activity on all joint tissues — cartilage, bone, muscle and ligament.8 Aerobic and resistance exercises have been shown to help with many of the physiological and psychological factors associated with arthritis: muscle weakness; decreased flexibility; poor endurance; fatigue; depression; and low pain threshold. All patients presenting with symptomatic osteoarthritis should be given education, an exercise prescription and suggestions for pain relief and weight loss. The importance of non-pharmacological treatments should be stressed early, and these treatments should be continued throughout the course of the disease. Non-pharmacological interventions are listed in Box 1. Not all have been evaluated in controlled trials and many have potential for a powerful placebo response (eg, massage, spa therapy). As osteoarthritis of the knee tends to be associated with the most disability, most clinical trials for osteoarthritis have been done in this patient group. Treatments supported by randomised controlled trial evidence for symptom relief in osteoarthritis are listed in Box 2. Most studies in patients with rheumatoid arthritis have focused on pharmacological interventions, but randomised controlled trials have shown that patient education, cognitive-behavioural therapy aimed at improving coping skills, exercise therapy and dietary changes to increase the intake of omega-3 oils can all reduce symptoms and improve quality of life. | |||||||||||||||||||||||
| Exercise and physical therapy (E1) | |||||||||||||||||||||||
| Exercise should be the leading non-pharmacological intervention for arthritis patients (Box 3). Exercises will also have benefits for a wide range of other conditions that are likely to affect an ageing population (osteoporosis, diabetes, hypertension, heart disease, stroke, depression and insomnia). It is recommended that the exercises should be prescribed to highlight their importance, but evidence-based recommendations for the exact type and amount of exercise are not available. | |||||||||||||||||||||||
| Exercise and osteoarthritis | |||||||||||||||||||||||
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All published guidelines for the management of osteoarthritis
include recommendation for exercises (aerobic, range-of-motion
and strengthening).3,8,10 There is no evidence for the benefit of
increased rest, supports or avoiding activity in osteoarthritis.
Several large-scale, well-designed studies have shown
improvements in aerobic capacity, walking time, depression,
strength and function after only 10 weeks of a moderate exercise
program.11-13 A recent review of the effectiveness of
exercise therapy in patients with hip and knee osteoarthritis
supported the benefit of exercise, but concluded that there were
insufficient data to recommend types and components of
exercises.14 No
deleterious effects have been documented, despite some programs
including quite vigorous activity among elderly subjects. One study
randomly allocated over 300 patients aged 65 years and over with knee
osteoarthritis to either an educational program or an aerobic and
strengthening program for three hours a week. The exercise group had
significant benefits in pain control and functional outcomes;
however, NSAID use was not regulated.15 A more recent
study16 randomly allocated elderly patients (mean age, 73 years)
with knee osteoarthritis to a progressive, home-based exercise
program, including resistance and strengthening, or to a control
program of range-of-motion exercises without resistance. Both
groups were given a standard dosing of NSAID and allowed escape
analgesia with paracetamol. While both groups improved from
baseline during the eight-week study, those with the progressive
exercise program using common items in the home showed greater
reduction in activity-related pain and greater improvement in
mobility and walking measures.
As being overweight and obese are also major risk factors in the development of osteoarthritis, exercise programs aimed at increasing energy expenditure and fitness and leading to weight loss should help to decrease the load on the involved joint and decrease pain. | |||||||||||||||||||||||
| Exercise and rheumatoid arthritis | |||||||||||||||||||||||
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Fitness and strength can be improved in rheumatoid arthritis without
causing an exacerbation of symptoms. A decrease in general activity
in rheumatoid arthritis can rapidly lead to a decrease in function.
Several major studies have shown significant improvements in
maximum aerobic capacity and muscle strength in only six
weeks.17 Anxiety
and depression scores have also shown significant improvements. A
systematic literature review of dynamic exercises for rheumatoid
arthritis was unable to pool the data, but concluded that there was a
positive effect of exercise without any detrimental effects on
disease activity.17
One of the major issues concerning rheumatoid arthritis and exercise involves learning to manage fatigue. Fatigue is a common complaint of any condition associated with chronic pain. Patients need help to manage the fatigue with the gradual introduction of exercises. Teach patients to observe fatigue in themselves, get them to gauge how much activity is possible before fatigue sets in, and try to ascertain whether the fatigue is caused by the disease process, "a flare", inactivity or depression, and manage accordingly. Achieving an improved level of aerobic fitness will reduce fatigue. | |||||||||||||||||||||||
| Compliance | |||||||||||||||||||||||
| Compliance with an exercise program is probably the major challenge for the clinician (and the patient!). To comply with an exercise routine, people need to have successful/positive experiences and to see and feel some benefit in the short term.18 Having someone else to exercise with and having supervision (eg, a physiotherapist in a group class) will also improve long-term compliance with exercise programs. Tips to encourage compliance are listed in Box 3. | |||||||||||||||||||||||
| Hydrotherapy/balneotherapy (E2) | |||||||||||||||||||||||
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Balneotherapy, or spa therapy, involves exercises in warm,
naturally occurring mineral waters, whereas hydrotherapy uses
exercise in locally available heated pools. It is one of the oldest
forms of therapy. A recent Cochrane review19 found 10 randomised
trials with 607 patients. Most trials reported positive findings
relating to muscle relaxation, reduced pain and improved sense of
well-being, but the scientific quality of most trials was a problem
and it was not possible to pool the outcome data. No trials have shown
any advantage over land-based exercises for improvement in muscle
strength. However, anecdotal evidence suggests that hydrotherapy
may be the gentle start that is needed to encourage patients to develop
their exercises further. People with arthritis are often more
compliant with a hydrotherapy exercise program, as it does not
increase their pain and they enjoy it as a social activity.
Hydrotherapy is also used widely for the rehabilitation process after total knee or hip replacement surgery. | |||||||||||||||||||||||
| Patient education and self-management programs (E2) | |||||||||||||||||||||||
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Patient education and self-help courses have been shown in
randomised trials to be cost-effective and associated with reduced
pain, increased well-being, increased knowledge, reduced use of
healthcare services and increased compliance with exercises, and
these effects have been shown to be sustainable for up to 12 months.
This has been shown for both patients with osteoarthritis and
rheumatoid arthritis.20 Education, specifically self-management
education, is also recommended by all evidence-based published
guidelines for osteoarthritis management.
These programs include information about disease processes, medications and their actions and reactions, together with goal setting for exercises and pain management strategies. They focus on patients taking more control of their disease. | |||||||||||||||||||||||
| Telephone support (E2) | |||||||||||||||||||||||
| Small studies have shown that monthly telephone calls to patients with knee osteoarthritis are cost-effective for reducing pain, improving function and reducing the number of visits to the doctor when compared with a usual-care group.21 This should encourage practitioners to inquire after their patient's arthritis rather than ignoring it. The arthritis is often of secondary importance when visiting the surgery, both in the eyes of the patient and the doctor. | |||||||||||||||||||||||
| Weight reduction (E3) | |||||||||||||||||||||||
| Many osteoarthritis patients, particularly women, are overweight. Obesity is a well-documented risk factor for development of knee osteoarthritis. There is also good epidemiological evidence that being overweight is strongly associated with the radiological progression and disability of knee osteoarthritis.6,7 Some studies have shown symptom relief with weight control programs,22 but no randomised trials have yet shown whether weight reduction can slow progression of the arthritis. However, like exercise, the general health benefits of weight reduction should make it one of the key goals in the management of osteoarthritis. | |||||||||||||||||||||||
| Viscosupplementation (E1) | |||||||||||||||||||||||
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Hyaluronan is the main component of normal synovial fluid. In
osteoarthritis the elasticity and viscosity of the fluid is reduced
due to degradation of the hylan polymers. Synthetic synovial fluid
preparations of varying molecular weight are available
internationally and are given as a course of intra-articular
injections on three to five occasions a week apart. The preparation
available in Australia is hylan G-F 20. The injections can be
performed by any medical practitioner experienced in knee joint
aspiration and injection techniques in their rooms using strict
no-touch aseptic technique.
A small number of randomised controlled trials suggest that intra-articular injections of a cross-linked polymer derived from hyaluronan can reduce pain, stiffness and physical disability associated with knee osteoarthritis for an average duration of six months when compared with placebo (saline) injections.23,24 A recent review of available preparations supports their use for symptom modification.25 Not all patients with osteoarthritis gain the symptom relief, and the more advanced the x-ray and clinical changes, the lower the rate of success. No disease-modifying or structure-modifying effects have been identified and the effect on natural synovial fluid and hyaluronic acid production remains to be determined. The product has been registered for use in Australia as a device, implying that it has only mechanical effects as a joint lubricant and shock absorber. However, it is only retained in the joint for about one week, yet symptomatic benefits can last for several months. It can be associated with temporary flares of increased pain and swelling in the joint post-injection. While open-label studies among patients with advanced knee osteoarthritis have suggested that some can delay surgery, this has not been tested in a long-term controlled setting. The treatment is not recommended in the setting of inflammatory synovitis, such as crystal-induced arthritis or rheumatoid arthritis. A number of different preparations of varying molecular weight are available internationally. A Cochrane review of the efficacy of these intra-articular preparations is currently under way. | |||||||||||||||||||||||
| Glucosamine and chondroitin sulfate (E1) | |||||||||||||||||||||||
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A number of trials have shown that these compounds, produced from
marine and animal cartilage, may offer symptom relief for
osteoarthritis equivalent to NSAIDs, with greatly reduced adverse
effects. Original studies have been criticised for poor methodology
and small numbers, but meta-analyses conclude that there may be
benefit.26 Studies
have evaluated purified forms of glucosamine and chondroitin
separately in doses of 1500 mg daily. We are unaware of any studies
evaluating the claimed added benefit of the combination of these two
agents, but, as both molecules are major components of the
proteoglycan matrix structure of the cartilage, it would seem
reasonable to use them in combination. They take three to six weeks to
provide benefit but can also have a sustained effect after treatment
is stopped.
A recently published study performed among patients with knee osteoarthritis over three years showed gradual deterioration and increased narrowing of the joint space on x-ray among patients receiving placebo, but no such deterioration among the glucosamine group.27 The authors concluded that glucosamine may help prevent cartilage breakdown if taken long-term (two to three years). The study has generated considerable editorial comment and debate. It has been criticised for the use of x-rays as the measure of cartilage structure and function. Further long-term studies using more sensitive measures, such as cartilage and bone turnover markers and magnetic resonance imaging, are required before these "nutraceuticals" can be considered disease- or structure- modifying agents for osteoarthritis. Trials so far have been performed in Europe, where the glucosamine is prepared as a pharmaceutical agent. There is no guarantee that products not prepared to the same stringent requirements will have the same potency or efficacy. However, they do appear to alleviate symptoms in some patients with osteoarthritis, they don't appear to have any significant side effects or toxicity, and laboratory studies suggest they have anabolic effects on chondrocytes in cartilage cultures. No published data are available on their use in rheumatoid arthritis. | |||||||||||||||||||||||
| Omega-3 oils (E2) | |||||||||||||||||||||||
| A number of studies among rheumatoid arthritis patients have shown that omega-3 oils, in doses of 4000-6000 mg daily, can result in a small but significant (and probably clinically important) reduction in joint pain and swelling.28,29 No published data are available on their effect in osteoarthritis, but if clinical inflammation is evident they may provide some benefit. | |||||||||||||||||||||||
| Antioxidants (E3) | |||||||||||||||||||||||
| Epidemiological studies have suggested that osteoarthritis subjects whose diets are richer in antioxidants, such as vitamin C, vitamin D and green tea, have slower progression of joint space narrowing on x-ray over long-term follow-up.30 Whether these agents can alleviate the symptoms of arthritis or prevent joint damage remains to be seen and the results of prospective randomised controlled studies are awaited. | |||||||||||||||||||||||
| Transcutaneous electrical nerve stimulation (TENS) (E2) | |||||||||||||||||||||||
| A recent review31 found seven trials evaluating TENS (n = 148) compared with placebo (n = 146) for pain relief in osteoarthritis of the knee. Knee pain and stiffness reduced significantly in active treatment compared with placebo, with the "high rate and strong burst" mode providing better pain control. There was considerable heterogeneity in the studies, and further studies would be required to reach a firm conclusion about the efficacy of TENS, but it appears to be a treatment worth considering when pain control is a problem. | |||||||||||||||||||||||
| Herbal therapies — capsaicin, avocado/soybean (E2) | |||||||||||||||||||||||
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Many patients take complementary or alternative therapies for their
osteoarthritis, few of which have been tested in randomised,
placebo-controlled trials. A review found five studies (of four
different herbal preparations).32 Only two studies of avocado/soybean
unsaponifiables could be pooled. These showed beneficial effects
for pain control, function and global arthritis assessment, as well
as a reduction in NSAID intake, without any serious adverse effects.
That review concluded that there was no convincing evidence either
way for the other preparations, one of which was capsaicin.
Topical capsaicin depletes substance P locally in the tissues, thereby reducing the chemical stimulation of the nociceptor pain fibres. Its benefits were initially documented for painful peripheral neuropathy. More recent reviews of capsaicin studies in osteoarthritis concluded that there was benefit for pain relief in osteoarthritis when compared with placebo, and all published guidelines for osteoarthritis management now recommend its use.33-35 | |||||||||||||||||||||||
| Low level laser therapy (LLLT) | |||||||||||||||||||||||
| LLLT is an alternative, non-invasive treatment for osteoarthritis that has its effect through photochemical reactions in the cells. A Cochrane Musculoskeletal Review group found five randomised trials among 112 laser-treated patients and 85 placebo laser patients. Pooling the data found no statistically significant benefits in pain, joint mobility or joint tenderness.36 The same group also reviewed the effectiveness of LLLT for rheumatoid arthritis and found that it may offer benefits for short-term pain relief and reduction of morning stiffness. The review recommended further controlled clinical trials. | |||||||||||||||||||||||
| Patellar taping (E2) | |||||||||||||||||||||||
| Medial taping of the patellar was shown in one small randomised trial to offer short-term pain relief for knee osteoarthritis.37 It is worth using as an adjunct to getting quadriceps isometric and resistance exercises started or to use before doing the activities that are limited by pain. | |||||||||||||||||||||||
| Walking stick (E3) | |||||||||||||||||||||||
| No evidence from randomised controlled trials is available for the efficacy of walking sticks for pain relief in osteoarthritis, but biomechanical studies have shown a reduction in pressures across the joint on weight-bearing if the stick is used appropriately in the contralateral hand. It is hypothesised that reduced loading should reduce wear and tear on lower limb joints. Patients with regular pain on mobilising lower limb joints should be encouraged to use a stick and view it as a joint protective device rather than a sign of "giving in" to their arthritis. Safe use of walking sticks is best taught by a physiotherapist. | |||||||||||||||||||||||
| Orthotics, heel-wedges (E2) | |||||||||||||||||||||||
| Lateral heel wedges may reduce the pain related to osteoarthritis of the medial tibiofemoral compartment of the knee.38,39 Orthotics with arch and metatarsal supports may alleviate the pain of osteoarthritic feet, but they have not been studied extensively in properly controlled trials. | |||||||||||||||||||||||
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| Further reading | |||||||||||||||||||||||
| Authors' details | |||||||||||||||||||||||
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Department of Rheumatology, Royal North Shore Hospital, St Leonards, NSW. Lyn M March, PhD, FRACP, FAFPHM, Senior Staff Specialist. Osteoporosis Australia, Sydney, NSW. Judy Stenmark, BAppSc, MPH, Chief Executive Officer.
Reprints will not be available from the authors. ©MJA 2001
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This educational supplement is supported by an Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 2001 Medical Journal of Australia. | |||||||||||||||||||||||
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