The necessity of a paradigm shift in the treatment of osteoarthritis

Osteoarthritis: a major cause for concern
>Osteoarthritis (OA), the wearing away of protective articular cartilage in a joint, is quite possibly one of the most important and pressing health concerns in the U.S. today, and is unfortunately one that will only continue to grow in the future. Current statistics report that 13% of individuals over 60 suffer from knee OA, and the risk of mobility disability (help needed to walk or climb stairs) attributed to knee OA is greater than any other medical condition in people over 65. Projections say that by 2020, the number of those with OA will double, due to growing obesity rates and the baby boomers entering their 70s and 80s. Those in the health professions are therefore no strangers to the fact that OA is one of the most pressing matters in the community today, and that proper strategies must be implemented to lower the occurrence of OA, save lives and reduce health-care costs. Yet somehow, many practitioners continue to manage it incorrectly.

Biggest risk factors for OA
OA can be explained as resulting from excessive stress applied to an area and exacerbated by susceptibility. Susceptibility to OA can be increased by genetic inheritance, age, ethnicity, and being female, all of which are unchangeable. However, the two biggest risk factors for OA, obesity and joint injury, are modifiable, and therefore must be the primary object of focus for its treatment. Obesity rates are expected to increase in the future, but if serious measures are taken to combat these figures, the rate of OA would decrease significantly as well. While some measures are being taken now, the emphasis on weight reduction must be strengthened to further deal with both issues. In regards to knee joint injury, a number of neuromuscular conditioning programs have been proven to reduce the risk of ACL injury (which many times leads to OA) by as much as 60%, but there is a huge lack in the implementation of these programs in the greater athletic population.

How and where current treatment strategies go wrong
Despite such prevalent occurrence rates and the imperativeness of effective treatment, OA is a condition that is poorly managed in clinical practice. The most glaring issue with current treatment is that, on the whole, it’s mainly palliative, meaning it alleviates OA’s symptoms and reduces its severity but don’t actually cure the disease itself. Current clinical management is often limited to the use of analgesics and/or anti-inflammatory medication, which are only moderately effective, while patients wait concurrently for a referral for total joint replacement, which are not always necessary. In recent years, a number of evidence-based guidelines have been released for OA management, yet in most instances, clinical practices have not yet instilled them. Where the overall paradigm here needs to shift is to intervene when structural changes are reversible, and health-care professionals need to reappraise their current treatment strategies to focus on modifiable risk factors for disease, symptom genesis and disease progression.

The need for a shift towards prevention and progression
It’s already been pointed out that prevention strategies should begin by focusing on reducing obesity and the occurrence of joint injury in the community, but if OA does develop, efforts should be centered on eliminating symptoms and halting disease progression, not just palliation. Comprehensive management should include a combination of treatment options, and in this case the recommended hierarchy of management should be non-pharmacological modalities first, then drugs, and then finally surgery. Due to the connection between obesity and OA, exercise should be highly encouraged since it increases aerobic capacity, muscle strength and endurance, and facilitates weight loss. Since mechanical factors can be responsible for making symptoms more likely to occur, therapeutic options that can modify joint forces like patella taping, braces, orthotics and osteotomies for the knee can also be effective. Perhaps one of the most needed developments, however, is the convergence of health-care professionals from all sectors to create a comprehensive and integrated model of OA management, which will facilitate the implementation of the best evidence, patient education, patient self-management and collaboration and communication between health providers. Such a model will help patients with an improved quality of life, reduced health care use, and increased satisfaction with health care. With such a focused effort and paradigm overhaul, the OA rate may be significantly reduced and millions will experience less pain and disability in their everyday lives.

-Summarized by Greg Gargiulo

-As reported in the Feb. 11 edition of the British Journal of Sports Medicine