Patient education and non-pharmacological interventions are important part of treatment in osteoarthritis-Hans Rasker


Rheumatological Conference Proceedings-IV

Patient education and non-pharmacological
interventions are important part of
treatment in osteoarthritis-Hans Rasker

Since the disease is not curable, good communication
between doctor and patient is crucial

LAHORE: Management plan in patients suffering from osteoarthritis should be individualized. Currently available pharmacological interventions provide only symptomatic relief while investigations are continuing for disease modifying interventions.  Patient education and non-pharmacological interventions are an important part of treatment of osteoarthritis patients. Drug treatment can be useful but one should not expect much and always be aware of co-morbidities. Since there is no cure in OA, good communication between the doctor and the patient is important which should include empathy, good attitude and friendship.  Surgery may help many patients. These views were expressed by Prof. Hans Rasker, Professor Emeritus and consultant rheumatologist at University of Twente from Netherlands.  He was giving a keynote lecture on Osteoarthritis: What is new during the recently held rheumatology conference organized by Pakistan Society for Rheumatology at Lahore from April 10-12, 2015.

Prof. Hans Rasker

Successful management of OA, he further stated, depends on good history, symptoms and impact on life, functional disability, functional requirement, patient’s expectations and the psychological factors.  For assessment of pain and function of OA Hip and Knee many questionnaires are used.  However, general measures in OA management consist of patient education, self management of OA which should improve pain, function fatigue and stiffness besides reduction in intake of medications. Massage is inconclusive but manual therapy is helpful for short term. The patients needs to be trained in gait and having a balance. Heat can be used to relive stiffness and cold can relieve muscle spasms and pain.  While planning individualized treatment, keep in mind the patients expectations, level of functional  activity,  joints involved, severity of the disease, co-existing medical problems, subjective problems and objective findings. Do take care of depression, anxiety and sleeping disorders. Advice the patient on weight loss, modify their activities, give them advice on exercise and patient’s self management.

Osteoarthritis, Prof. Rasker said was a slowly progressive disorder associated with low grade inflammation. It may affect the joints of hands, spine, hip, knees, and toes. Some of the symptoms include pain, crepitus, and stiffness after immobility and limited function. OA cause more disability in  the elderly than any other disease and 80-100% of patients have co morbidities like heart disease, cerebrovascular disorders, diabetes, obesity, incontinence, problems with coordination and depression. For prevention non-pharmacological therapy, pharmacological therapy like NSAIDs and topical analgesics, Neutriceutical and surgical interventions are also useful. Primary prevention includes reducing the number of road traffic accidents, regular exercise and avoiding overweight. Secondary prevention consists of preventing worsening of the condition, losing weight, regular exercise and joint protection.

Speaking about the aims of treatment in OA, Prof. Rasker said that control pain and swelling, improve function, stop or slow the progression of damage of cartilage, bone and ligaments, minimize disability and improve quality of life of the patient.  It is extremely important that one should look for the cause of the real pain in OA. Shoulder pain has more than thirty causes.  Hip pain is often due to trochanteric bursitis while pain in hand or shoulder could be due to carpal tunnel syndrome. Almost 90% of cause of foot pain is due to small shoes. In such patients one should not only look at the foot and ankle but also at knees, hip and whole person even if one is too busy in the clinic.  Too small shoes and too high heels are also cause of foot pain. Successful management of OA consists of good history and physical examination, looking at the extent of abnormality, origin and level of pain, degree of inflammation, instability of joint, muscle condition besides soft tissue and neurological disease.

Treatment of OA, Prof. Rasker opined depends on sex, age of the patient, obesity, type of work, social life and quality of life. If there are co-morbidities like anxiety and depression, it also matters a lot and needs appropriate therapy. As such treatment in OA patients needs to be individualized based on patient’s expectations. Hence, one should design the therapeutic goal after discussion with the patient, follow the treatment targets and adjust treatment if necessary.  Various professional bodies like Osteoarthritis Research Society International (OARSI) National Institute of Health and Clinical Excellence (NICE) from UK, EULAR, and ACR have come up with guidelines for treatment of OA. Non pharmacological therapy consists of patient education, general weight loss, physiotherapy and modifying one’s activities. Drug therapy includes NSAIDs, topical analgesics and injections. In non-pharmacological therapies patient education, weight loss, physiotherapy, joint protection, orthotics and bracing are useful.

Obesity Prof. Rasker stated is an important factor in occurrence and progression of knee OA. Weight reduction has been associated with reduced pain, disability and progression. The patient should be advised to modify their activities of daily living and this advice should depend on the joints affected and co morbidities. Physiotherapy aims at maintaining and improving joint mobility, pain and functions. Exercises adapted to the joint affected decreases pain and improves function and muscle strength. It is useful especially in knee OA more than in Hip OA. Moderate two to six months exercise offers small benefit after cessation. It reduces knee pain besides improving physical functions and the effect is comparable to the use of NSAIDs.  Ultrasound in knee OA has little or no proven effect. Manual therapy may have some effect in back and neck OA but best results are achieved when it is combined with exercises. Splints, walking aids, safe environment, good shoes, use of shock observers, lateral wedge insoles knee of OA, knee braces and other joint protection devices are all helpful.

Talking about pharmacological therapy in management of osteoarthritis, Prof. Rasker mentioned topical therapies, paracetamol, NSAIDs, narcotic analgesics like tramadol, intra-articular corticosteroids, treatment of depression and anxiety. FDA has approved topical 1% diclofenac for treatment of OA. Topical capsaicin used every six to eight hours may also give some relief. Intra articlar corticosteroids are most effective when there is evidence of inflammation or effusion. They should not be used more than four times a year. It has few side effects and there is no long term proven benefit. Use of Glcosamine sulphate improves pain and function in knee OA. Recent trials have shown good effect of Chondroitinesulfate in knee and hand OA. It improves pain and functions besides reducing cartilage loss. Acupuncture may improve functions and pain in knee OA but it is not clinically significant.

In the surgical interventions Prof. Rasker mentioned lavage and joint debridement arthroscopy but the results differ. Other interventions include arthodesis, osteotomy and joint replacement. Since no trials are needed to introduce any new prosthesis, there are over sixty kinds of total hips available in Holland, he remarked.

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