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Osteoarthritis of the Knee and Hip:

Osteoarthritis of the Knee and Hip:

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.

Table 1 - Nonpharmacologic treatment guidelines for osteoarthritis of the hip and knee
Patient education

Self-management programs (eg, Self-Managed Arthritis Relief Therapy)
Health professional social support via telephone contact

Weight loss (for patients who are overweight)

Physical therapy
Range of motion exercises
Strengthening exercises (eg, quadriceps strengthening for knee osteoarthritis)
Assistive devices for ambulation
Occupational therapy

Joint protection and energy conservation
Assistive devices for activities of daily living
Aerobic exercise

Orthoses and bracing

Lateral wedge for genu varum deformity

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.

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 mail-delivered 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.

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