Osteoarthritis of the Knee and Hip: Practical Nondrug Steps to Successful Therapy
ABSTRACT: For patients with osteoarthritis, nonpharmacologic treatment can be an effective adjunct to drug therapy. Patient education is essential; both communitybased and independent self-care programs are available. Weight loss can improve function and alleviate symptoms; however, it is more effective when dietary modification is accompanied by increased physical activity. Physical therapy, including home exercise, may involve range of motion exercises to prevent loss of motion and quadriceps strengthening to relieve pain and improve function. In occupational therapy, patients learn proper techniques for joint protection during activities of daily living. Participation in aerobic conditioning programs improves aerobic capacity and walking speed. Orthoses may relieve pain and enhance joint stability. Key words: osteoarthritis, physical therapy, occupational therapy _________________________________________________________________________________________________________________________ Arthritis and other rheumatic conditions are the leading cause of disability in adults in the United States. The cost of this public health burden is significant and is expected to increase as the US population ages.1 Osteoarthritis (OA) is the most common form of arthritis (Figure 1). Typically, patients with OA have pain that worsens with prolonged activity and weight bearing and improves with rest.2 Nearly one sixth of patients with OA report that the disease limits their daily activity.3 There is no cure for OA, but treatment tailored to the individual patient can reduce its impact. Nonpharmacologic strategies can be extremely effective in controlling pain, maintaining joint motion, and limiting other symptoms of OA, thereby improving function and minimizing disability (Table 1). Although nondrug approaches should be viewed as complementary to pharmacologic treatment, they are needed to maintain the health of both arthritic and normal joints. They also may help limit the use of analgesics and spare patients from the adverse effects of medications. In 1995, the American College of Rheumatology (ACR) published guidelines for the nonpharmacologic management of OA of the hip and knee; these were most recently updated in 2000.4 The guidelines focus on a combination of patient education, follow-up, and support to ensure patient compliance; weight loss; physical and occupational therapies; judicious use of exercise; and use of adaptive equipment and bracing. In this article, we review these updated recommendations and offer advice for their implementation in a primary care practice. Figure 1 – This x-ray film shows severe left-sided joint-space narrowing and sclerosis and some marginal osteophytic changes in a patient who has osteoarthritis. Note that the symptoms are much less pronounced on the right side. PATIENT EDUCATION The first step in any nonpharmacologic treatment program is patient education delivered through discussions during office visits. Study results have consistently shown that the more aware and educated a patient is about his or her disease process, the clearer his perception of his pain and function becomes. In fact, use of these educational programs may result in improvement comparable to that achieved with NSAID therapy.5 Also, it may be helpful to supplement in-office discussions with handouts for the patient to take home and refer to. Patient-specific management programs. Other options for patient education include traditional peer-led, community-based Arthritis Foundation self-management programs. More recently, patient-specific maildelivered management programs, such as the Self-Managed Arthritis Relief Therapy (SMART) program, have been developed to target a patient’s individual disabilities.6,7 Typically, patients who participate in these programs report decreases in joint pain and arthritis-related physician visits, as well as increases in physical activity and overall improvement in quality of life.6 Materials include videos, pamphlets, and newsletters from the Arthritis Foundation (visit the foundation’s Web site at www.arthritis.org) or other national health organizations. These materials can be used to reinforce the benefits of a self-management program. In long-term, randomized, controlled trials, Lorig and associates7 found that a mail-delivered SMART program was similar in effectiveness to a traditional classroom-led, community-based self-management program. Patients who were educated by way of mail-delivered educational material or through community-led programs for 18 or 6 months, respectively, continued to have improvements in function, along with decreases in global severity of symptoms and physician visits, for up to 2 years after the intervention. The various modes of delivery allow you to tailor educational interventions to different populations and to provide alternatives for patients who are less willing to participate in classroom sessions or who have scheduling difficulties. Structured social support. This can be provided for patients with OA through monthly telephone calls from trained nonmedical personnel. Calls are designed to reinforce lessons learned in self-care educational programs. Topics of discussion include joint pain, medications and treatment compliance, drug toxicities, date of next scheduled appointment, and overcoming barriers to keeping clinic appointments. Moderate to large improvements in pain and functional status have been seen with increased telephone contact, without a significant increase in cost.8 Mazzuca and colleagues9 studied 165 patients with knee OA who learned problem-solving and joint protection techniques and, subsequently, reviewed the material using standardized questions during telephone conversations at regular, predetermined intervals. The authors found significant functional preservation and control of resting knee pain and concluded that this intervention should be included in the management of OA. However, many physicians’ offices do not have a nurse specialist or other trained personnel on staff who can perform this personalized social support. WEIGHT LOSS This nonpharmacologic intervention can be effective in both prevention and management of OA. To date, most of the evidence for the beneficial effects of weight loss has come from observational studies that demonstrated an association between high body mass index (BMI) and the incidence of OA and an association between weight loss and symptom reduction. In the Framingham Study, losing even small amounts of weight was found to be an effective primary prevention against the development of symptomatic OA.10 In women with baseline BMI values higher than the median, weight loss of approximately 11 lb during the 10 years before the study decreased the risk of symptomatic knee OA by more than 50%. Conversely, weight gain was associated with a slightly increased risk of subsequent knee OA. To date, evidence supporting weight loss as a single therapeutic intervention for reducing symptoms has not been provided by large randomized, controlled trials. In several studies, however, results have indicated that in patients who are overweight, loss of weight through the use of anorectic agents or through surgical interventions, such as gastric stapling, may improve function and alleviate the symptoms of OA. Weight loss alone may not be as effective when achieved exclusively through dietary means and at the cost of a resultant loss in lean body weight. Toda and coworkers11 found that symptomatic benefit is more closely associated with loss of body fat than with loss of body weight. Without concomitant exercise of lower extremities, weight loss may involve loss of lean body mass and, in particular, loss of muscle strength that may compromise the protective effects of lower extremity muscles during impact loading.12 Weight loss in conjunction with some form of exercise may be more beneficial than the use of diet alone to achieve weight loss. In a randomized, single-blind study of overweight older persons with knee OA, the combination of modest weight loss and moderate exercise provided greater overall improvements in selfreported measures of function and pain, as well as in performance measures of mobility, than did either intervention alone. In addition, dietary weight loss alone did not result in significant improvements in mobility (an important determinant of disability) or self-reported function and pain.13 These findings suggest a need for effective use of both dietary modification and exercise. PHYSICAL THERAPY The realization that structured exercise programs can improve the functional capabilities of patients who have OA without exacerbating symptoms has altered the approach to treatment. Physical therapists who help assess patient mobility, instruct patients in how to perform therapeutic exercises (including range of motion and periarticular muscle strengthening), and explain the use of assistive devices can play an invaluable role. An initial plan for physical therapy in patients with OA of the knee or hip or both includes about 4 weeks of physical therapy, 2 or 3 times per week. This regimen is followed by an office visit to review the patient’s progress. If the patient is making gains with physical therapy but specific goals have not yet been met, consider additional physical therapy. If the patient has met all the therapy goals that were set at the first physical therapy visit, consider a home exercise program. During subsequent office visits, assess performance of and compliance with the home exercise program. Range of motion exercises. In osteoarthritic joints, range of motion exercises can help prevent motion loss that commonly occurs with disease progression or disuse or both. If it is not put through a full functional range of motion regularly, the knee joint is especially susceptible to loss of flexion caused by bony ankylosis and soft tissue contractures. Both flexion loss and extension loss can adversely affect a patient’s function. In particular, loss of flexion can make it difficult for patients to negotiate elevations, such as stairs or curbs. Loss of extension can place the quadriceps muscles at a disadvantage during ambulation; the functionally shortened quadriceps cannot rest completely during the extension phase of gait. A therapist can help address these deficits by putting a patient’s joint through an arc of motion to restore and maintain as much functional range as possible. Treatment can be tailored to the individual patient’s needs. If, for example, the patient has full and unrestricted range of motion and adequate strength to move a joint, he can actively range the joint by himself. If the patient has limitations in motion, the therapist can help him complete the motion by using active assisted exercises. Quadriceps strengthening. Most of the literature on the use of strengthening for OA management pertains to quadriceps strengthening for knee OA. Quadriceps weakness is common in patients who have OA and has been shown to correlate with pain severity.14 Such weakness may be present in persons who have radiographic changes consistent with OA even before the development of knee pain and muscle atrophy.15 Quadriceps-strengthening exercises have been shown to be effective in relieving pain and improving function in patients with knee OA, even older persons.16 In the Fitness, Arthritis, and Seniors Trial (FAST), older patients with mild disability were randomly assigned to quadriceps- strengthening or aerobic exercises. Both groups showed moderate sustained improvements in pain and disability for up to 18 months after treatment. A strength-training program can be tailored to the abilities of the patient. Muscle strengthening can be achieved with isometric, isotonic, or isokinetic exercises. Isometric exercises (pushing or pulling against static resistance) can be used to initiate a training program or to maintain strength in a patient who has an exacerbation of symptoms. In an isometric exercise, there is little overall change in muscle length and, therefore, in joint motion. In quadriceps sets, for example, the patient contracts the quadriceps muscle and maintains the contracted position during long periods of either lying supine or sitting. In isotonic strengthening exercises, a muscle contracts and moves a joint against a fixed external load. Because the load remains constant, the joint movement occurs at variable speeds. In contrast, however, during isokinetic strengthening exercises, a patient moves a joint at a constant speed against variable external resistance. Open- and closed-chain exercises. Both isotonic and isokinetic exercises can be classified into openchain and closed-chain kinetic exercises. In open-chain kinetic exercises, such as leg extensions, the foot is free to move and motion at the knee is independent of hip and ankle motion. In closed-chain kinetic movements, such as a leg press, motion at the knee is accompanied by motion at the hip and ankle. Whether isotonic or isokinetic exercise is more effective is unclear. However, open- and closed-chain exercises have differences that may be important in quadriceps-strengthening exercises for patients who have OA. Open-chain exercises can increase patellofemoral forces, particularly at mid range of motion.17 This can be problematic if the patellofemoral knee compartment is affected by the osteoarthritic process, because forces generated during open-chain exercises can aggravate a patient’s symptoms. In our experience, open-chain quadriceps-strengthening exercises often cause exerciseinduced arthralgias in patients with OA of the knee and generally should be avoided. In contrast, closed-chain kineticstrengthening exercises, such as the leg press and wall slide, can be highly effective for quadriceps strengthening and are well tolerated when performed correctly. Also, these exercises can be adjusted to target the medial (vastus medialis obliquus [VMO]) or lateral (vastus lateralis) quadriceps muscles. For example, by simply placing a rolled-up towel or therapy ball between the knees and squeezing the thighs together to prevent the object from falling, the patient can strengthen the VMO. This exercise can be particularly effective in patients who have OA that involves the patellofemoral compartment, in which there may be excessive lateral tracking of the patella.18 Relative weakness of the hamstring muscles is also present in patients with knee OA.19 An exercise prescription should include hamstring-strengthening exercises, such as prone leg curls. The literature describing the use of exercise for management of hip OA is not nearly as extensive as it is for knee OA. According to general principles of exercises for osteoarthritic joints, however, muscle groups acting on a particular joint should be strengthened to provide muscular support for the joint. In addition, those same muscle groups should be stretched to avoid exerting abnormal forces on the joint. Strengthening exercises for hip OA include hip abduction, adduction, flexion, and extension against resistance. In a hip abduction–strengthening exercise, the patient lies on his opposite side and abducts his affected hip. The patient can make the exercise more challenging by wearing an ankle weight on the leg that he is abducting. Home exercise program. After a patient completes a physical therapy program, most therapy facilities prescribe a discharge home exercise program and provide a handout that details the recommended exercises. If this material has not been sent to your office as part of a discharge therapy note, ask the patient to bring the material to the next visit. During subsequent follow-up visits, the material can be reviewed with the patient until it is clear that he understands the information and is following the program. In our experience, sending a patient to physical therapy without discussing and monitoring the home exercise program almost always leads to noncompliance. Generally, a patient who is enrolled in physical therapy should be taught exercises that he can eventually perform independently as part of a home exercise program. During follow-up office visits, question the patient about his ability to perform the home exercise program and his compliance. At times, it may be necessary to ask the patient to demonstrate some of the exercises. If the patient cannot perform the exercises independently, he needs to return to physical therapy for more training. OCCUPATIONAL THERAPY A short course with an occupational therapist can be valuable. The therapist instructs the patient in proper activities of daily living and in joint protection techniques, such as using correct patterns of motion, avoiding positions of deformity, and avoiding remaining in one position for prolonged periods (Table 2). A therapist also can recommend adaptive equipment that may help improve function. An occupational therapist can provide appropriate ergonomically designed assistive devices that help patients perform activities of daily living, including work-related tasks, without unnecessarily excessive joint forces. For example, a patient can use a long-handled shoehorn to put on shoes without going into deep knee or hip flexion (Figure 2). Other recommended assistive devices include raised (elevated) toilet seats, sock aids (devices that help patients put on socks), and tubular slip-on devices to place on handles of eating utensils that are designed to help patients with hand OA more effectively grip various instruments. AEROBIC EXERCISE Compared with age-matched controls, patients who have OA exhibit decreased aerobic capacity, which may have an adverse impact on overall morbidity and mortality.20 Participation in aerobic conditioning programs not only improves aerobic capacity and walking speed but also tends to ameliorate symptoms of depression and anxiety.21 In addition to its beneficial effect on overall health and weight loss, aerobic conditioning is believed to produce an analgesic effect via the release of endogenous opioids.22 Although most physical therapy programs incorporate some form of aerobic conditioning (eg, walking, jogging, bicycling, or stair climbing), patients also should be encouraged to participate in regular aerobic exercise after completion of therapy. In addition to decreasing pain and perceived disability, aerobic training may improve the patient’s balance and proprioception, thereby decreasing the risk of falling. In a follow- up to the FAST study, patients who participated in a walking intervention had better postural sway and single-leg stance balance than did those who performed strengthening exercises.23 Aerobic exercise options include a physical therapist–supervised exercise program, a walking program (for patients with less debilitating symptoms), and a local aquatic therapy program (for patients who may need weight off-loaded by the buoyant effect of water). For more information about services in their area, direct patients to a local Arthritis Foundation aquatic program or to the Arthritis Foundation Web site. ORTHOSES AND BRACING Braces, shoe inserts, and other orthotic devices offer another treatment option for select patients with symptomatic OA. Orthoses may relieve pain and enhance joint stability. The knee and foot regions generally are more amenable to orthotic intervention than is the hip. Appropriate orthoses for the knee range from simple tape and elastic bandages to knee braces that can limit knee range of motion as needed. Even wearing a simple elastic bandage improves knee proprioception and can result in improved gait mechanics.24 A common bracing option for patients with symptomatic patellofemoral compartment involvement is medial taping of the patella. Such taping helps decrease pain and limits lateral patellar facet forces.25 Often, we order a trial of McConnell, or patellar, taping as part of a physical therapy program for patients with symptomatic patellofemoral compartment OA. If patellar taping is effective, a patellastabilizing neoprene sleeve can be ordered. For some patients, a lateral wedge insole is another effective treatment option. A simple foam insert placed in a normal shoe of patients who have medial compartment OA or those with genu varum deformity without concomitant significant ankle valgus deformity can improve pain and decrease abnormal biomechanics.4 In a study conducted by Keating and colleagues,26 61% of knees in patients who had medial compartment OA had improvements in pain with use of a simple insert. ASSISTIVE DEVICES FOR AMBULATION These devices can help decrease forces acting across lower extremity joints and, by widening the base of support, provide stability. Factors to consider in the choice of an assistive device include the amount of stability needed and the desired degree of lower extremity force diminution weighed against the increase in energy demands of ambulation. For both hip and knee OA, the ACR guidelines recommend using an assistive device in the hand opposite the affected side to decrease pain and improve function.4 In particular, use of an assistive device contralateral to the more affected osteoarthritic hip more effectively reduces ground reaction forces on the hip and ipsilateral hip abductor contractile forces that excessively load the joint. Contralateral use also minimizes energy expenditure by keeping the center of gravity medial to the weight-bearing foot and close to midline. For knee OA, the issue of in which hand to hold the assistive device is somewhat controversial.27 However, use in the hand contralateral to the more affected joint widens the base of support and more closely simulates normal gait (the ipsilateral leg and opposite arm come forward at the same time). In our experience, patients intuitively use the assistive device on the same side as the primary pathologic condition unless they are instructed to do otherwise. 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