Friday 12th October was World Arthritis Day! A day to improve awareness and the management of arthritis. Studies show that up to 25% of us suffer from “Arthritis” and this is only increasing with the aging population, sedentary lifestyles etc.
So I wanted to discuss the best treatment options for “Arthritis”, as most people seem to fall into one of two false belief categories:
1. There’s nothing I can do and I just have to put up with it
2. the only answer is to have surgery
Now both beliefs are, unfortunately, just plain wrong. But it’s not your fault if you believe this. Most of the information out there paints arthritis as disease of no cure and no hope besides the scalpel.
(Now I should point out that today I am mainly referring to osteoarthritis (OA) – which would normally be referred to “wear and tear” type arthritis. There are many other different types of arthritis, which can be systemic, genetic, autoimmune related etc. These will require different treatments as well, which are often medical. By far the most common type of arthritis is osteoarthritis so I will focus on this today).
The most important thing to be aware of in treating your OA is that how it looks on the scans and how it feels can be completely unrelated. There are many studies now showing OA changes are very common as we get older in people who have never had pain! This means just because you have OA on an x-ray doesn’t necessarily mean you’ll have pain. In fact, in the clinic we find lots of people have been told they have OA as a throw away diagnosis based on their x-ray, when in fact their knee pain may have been caused by something different (and curable) entirely.
Just because it looks like arthritis on your scan doesn’t mean you are stuck with a life of pain!
So because of this, we know that even though we can’t change how the joint looks, we can certainly change how it feels. Why do some people with “arthritic changes” on their scan have pain and some don’t? It can’t be just because of the OA.
The key to optimal management of OA is ensuring everything else is working well! The better your strength and muscle function is around the joint, the better supported the joint is and the better shock absorption your muscles can provide. This means less load on your joint and less pain.
The better your joint mobility is, the more your joint can tolerate and the less pain you’ll have.
So the number 1 best treatment for arthritis is……
Particularly focussing on
1. Mobility, and
There’s also an extra benefit of exercise (I covered it in my previous article here) and that is the joy of mechanotherapy. This is like the opposite of “use it or lose it”
The reason our muscles get stronger when we lift weights is the tissues respond to stress and increased load demands by adapting (by getting stronger). It’s not only your muscles that respond this way. All the tissues in your body can respond to mechanical stress to improve their capacity. (this is also why weight bearing exercises is highly recommended for people with osteoporosis, and why astronauts all get osteoporosis).
Exercise and strengthening actually promotes stronger cartilage in the joints!
Now the conventional wisdom for many years was that doing more actually made the arthritis worse (or would speed up the wear and tear process). We now know that this is incorrect. That avoiding exercise and activity actually can lead to worsening arthritis symptoms and more pain.
Just think – we are the most sedentary we’ve ever been, and the rates of arthritis are increasing.
Of all the conservative treatments (not surgery) available to us, Exercise has the greatest treatment effect with some of the lowest risks. Recent studies have found exercise is more effective than pain medication, weight management, supplements, dietary changes and education.
The other amazing benefit of regular strengthening exercise is it appears to have an analgesic effect (as in it reduces pain) without drugs or surgery. Regular strength training has been proven to reduce pain in people with hip and knee arthritis!
Now the next most useful option to managing OA symptoms is actually weight management. (This comes back to reducing the loads on the joint again). Studies have found a 10% reduction in body weight (for those regarded as overweight) led to a 40-50% reduction in knee pain in people with OA. Conveniently, this is another common side effect of regular exercise.
So what about surgery?
Now sometimes, surgery is the right thing to do. Our beloved physio Jane has recently undergone a hip replacement (but her hip looked more like a crocodile’s jaw than a smooth ball and socket). However, she had been successfully managing her advanced OA for many years and keeping her pain under control with disciplined strengthening and pool exercises. Only now had it gotten bad enough to warrant surgery. (and to be honest most people’s hips aren’t nearly as bad as Jane’s was).
In the exception of very severe cases like this, there’s actually a lot of evidence around that the outcomes following surgery for arthritis (particularly knee OA) really aren’t any better than exercise anyway. The long-term outcomes on pain, disability and quality of life are pretty similar for surgery as they are for exercise management (and in some cases exercise definitely comes out on top). Add to that the cost of surgery would be more than 10x higher than exercise intervention with a physiotherapist, and the fact the risks associated with surgery are much greater. Why would you opt for surgery with mild to moderate OA if you haven’t tried any of these other interventions first?
A recent study took people on a waiting list for surgery for knee and hip OA and implemented a structured exercise-based program for them to follow instead. Following this, most of the participants chose not to have surgery! They had gained enough benefit from the exercise program that they didn’t need surgery any more.
So what should you do?
So if you have been told you have arthritis (particularly OA) and there is nothing you can do, or having surgery is your only option, then you need to read this. It makes no logical sense that people with mild to moderate OA would go straight to surgery if they haven’t at least tried strengthening and exercise (and appropriate weight management) first. The costs and risks of surgery vs the benefits really show that exercise should be the FIRST treatment of choice for anyone with joint pain due to OA.
If you are carrying too much weight, then adding some sort of steps to reduce you bodyweight a bit will also help. Remember, the study showed 10% reduction in body weight reduced pain. Just a little change can be helpful if you are overweight.
The key with exercise intervention (as with anything) is doing the right type and the right amount. That’s why if you are in pain you should be supervised and provided a program by someone who understands pain and pathology, and who knows what will and won’t benefit you.
If you have been told you need a clean out surgery, or if you’ve even been told that your only choice is a joint replacement, I would strongly recommend you look into strengthening first. Many times you can find you don’t need surgery after all. Or the worst that can happen is your results from surgery will be far better (you need to do exercise as rehabilitation after surgery anyway). And we know that the stronger you are before surgery, the better your outcomes are after surgery. (this is how Jane has managed to be back at work less than 6 weeks after a hip replacement – she worked very hard before hand to ensure she would have a good outcome.)
Take home message:
The best treatment for arthritis is unquestionably exercise and strengthening. You have to do the right type, and the right amount. And it’s not a quick fix like we perceive surgery to be (even though there’s a lot of recovery time after surgery). But in many cases investing the time and effort into improving your strength and capacity will mean much less pain, much better function and quality of life, and NO surgery.
Julian is a Director and manager at BodyWise Physiotherapy. He has spent over 13 years working exclusively in private physiotherapy practice, and estimates he has performed close to 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues. He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries.
Brignardello-Petersen R, Guyatt GH, Buchbinder R, et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open. 2017;7(5):e016114. doi:10.1136/bmjopen-2017-016114.
McAlindon, et al, OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88. doi: 10.1016/j.joca.2014.01.003. Epub 2014 Jan 24.
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