Opinion statement
Osteoarthritis (OA) is a leading cause of disability in the USA. Numerous clinical practice guidelines specify non-pharmacological strategies as the core management approach for OA. Although several of these strategies are efficacious, clinical practice remains primarily focused on analgesic use and invasive treatments such as joint replacements. This practice gap may be due to several factors such as a lack of accessibility or awareness of non-pharmacological interventions in clinical care, concentration on pain alone—which neglects other disability-related symptoms such as fatigue, and sleep difficulty, and placement of prevention and wellness with this lifelong disease as lower priority on the part of providers and payers. As referral patterns to rehabilitation for OA are scant, future research should focus on how to package established non-pharmacological interventions and increase accessibility at the point of care when patients are seeking services. Providers then would have the means to link patients to the plethora of community resources for OA management. Furthermore, a more holistic approach to symptom management that targets physical activity, diet, education, and behavior change is needed, with interdisciplinary healthcare professionals playing a larger role in tailoring non-pharmacologic interventions to individuals.
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Introduction
Osteoarthritis (OA) is the most common form of arthritis, affecting approximately 27 million adults in the USA [1]. It is a disease of the joint and joint structures that has no cure and most often affects the hands, knees, and hips. People with OA often experience joint-specific pain and functional limitations. However, OA pain is not necessarily limited to the joint. An emerging heterogeneous phenotype of OA includes joint pathology, psychological distress, and neurological processing of pain [2–4]. Within this complex pain model, centralized pain has been associated with additional health-related issues such as insomnia, depression, and fatigue [4–6].
Typical treatments for OA are focused on reduction or elimination of joint pain through medications or total joint replacement surgery. Unfortunately, these treatment options are most likely to occur in advanced stages of the disease and may not adequately serve the needs of many people with OA who can live for years, or even decades, with this chronic condition. As evidenced by the new phenotype of OA that is inclusive of psychological distress, the effects of OA often extend well beyond the joint. Patients may experience disability in their usual daily activities, reduced participation in valued activities, and diminished social roles (e.g., reduced capacity to work, volunteer, or caregiving) [7, 8]. Disability in OA may also vary depending on which joint or joints are affected (knee or hip OA). The risk of disability due to knee OA in particular is greater than that of any other chronic condition [9]. As OA increases in prevalence with age, comorbidities also have an effect on overall pain and disability. Specifically, OA is highly comorbid with obesity and type II diabetes [10–12]. Considering the inherent risks associated with pharmacological management of multiple comorbidities and surgical intervention for management of OA, it then follows that clinical practice guidelines recommend utilization of non-pharmacological approaches as fundamental to the treatment of OA [13, 14].
Integrating non-pharmacological interventions into OA care supports the key areas of exercise and physical activity, weight management and healthy nutrition, rehabilitation, and self-management education. The following article will focus on ideal practice and the state of the science in OA management using non-pharmacological approaches.
Non-pharmacological treatment options
Exercise
Exercise is one of the most extensively researched non-pharmacological interventions in OA. Among people with knee OA, there is strong evidence that any type of exercise has small to moderate positive effects on pain and physical function [15, 16] and small effects on quality of life [15]. These effects equated to absolute improvement of 12 % for pain, 10 % for physical function, and 4 % for quality of life for people in exercise groups compared to those who were not in exercise groups [15]. Further, these effects have been sustained between two and six months post-cessation of the intervention. No differences have been found for the types of exercise (e.g., aerobic vs. resistive) [17]. A recent meta-analysis of exercise dose and type for knee OA showed that although all types of exercise were effective at reducing pain and improving reported physical function, stronger effects were shown when one type of exercise was the focus, when the program was supervised, and for programs that involved three sessions per week [18]. Fewer clinical trials are available evaluating the effectiveness of exercise in hip OA. In two recent meta-analyses, one examined effectiveness of land-based exercise, aquatic exercise, and manual physical therapy involving 19 studies [19] and the other examined effectiveness of land-based exercises involving ten studies [20]. Both meta-analyses concluded that exercise had at least small effects on pain in the short-term compared to a control condition [19]; although one meta-analysis concluded that pain and physical function only improved slightly among people with hip OA (8 and 7 % improvement, respectively) [20]. Like exercise, weight loss and dietary interventions have also been shown to reduce pain and improve function.
Weight loss/diet interventions
A large prospective study [21] found that BMI, weight, waist-hip ratio, and percent body fat was associated with increased incidence of both knee and hip OA. Accordingly, weight loss is recommended for people with lower extremity OA who are overweight [22, 23]. Most studies have included people with knee OA only [24], and in high quality studies, the effects on pain and physical function were small [25, 26]. Nevertheless, the combination of weight loss plus exercise has led to the greatest improvements in symptoms and function [26, 27]. Messier and colleagues [28••] examined the effects of an 18- month intervention of intensive weight loss (with a goal to lose 10 % of body weight), aerobic exercise, or a combination of the two on pain, physical function, inflammation (IL-6), and knee compressive forces. The combination of diet plus exercise led to greater weight loss (11 % of body weight compared to 10 % in the diet alone group and 2 % in the exercise alone group). The combined group also showed the largest improvements in pain and function compared to the other groups. Additionally, knee compressive forces improved in all three groups. More weight lost, regardless of group assignment at baseline, was associated with better knee compressive force, lower IL-6, decreased pain, and improved function at 18 months.
Unsurprisingly, animal models have linked high-fat diets in particular to increased obesity, increased IL-6, Type II diabetes, and accelerated progression of OA [29–31]. Although biomechanical factors such as elevated BMI have been noted to play a role in knee and hand OA, some studies suggest that metabolic dysfunction in particular, as evidenced by elevated HgA1c levels, may play an even greater role in accelerated OA progression compared to weight alone [32–34]. Therefore, specific dietary recommendations should focus on reducing intake of foods with a high glycemic index [35] (potatoes, rice, sugar, processed foods, and foods with high trans-fat) and increasing intake of proteins, fruits, vegetables, monounsaturated fats (such as olive oil), and polyunsaturated fats (like flaxseed oil). Olive oil especially has demonstrated some evidence of reducing cartilage degeneration when combined with exercise [36].
Weight loss and dietary interventions for OA can be challenging for individuals to implement as food choices are often reflective of culture, income, and habit. Providers should advise all overweight patients on weight loss and dietary modifications, suggesting some daily physical activity and setting small weight loss goals such as an initial loss of 10 % of total goal at a safe rate. In addition to weight loss and dietary interventions, some individuals may require a more hands-on approach for OA management as offered through rehabilitation programs.
Rehabilitation interventions (physical and occupational therapy)
Manual therapy
Manual therapy is used in rehabilitation and may also be provided by chiropractors or other practitioners. This therapy involves mobilization of affected joints, muscle massage, and stretching. Although this is a recommended intervention from clinical practice guidelines [37, 38]; there is limited evidence to support its effectiveness. Problems with synthesizing the evidence base include the heterogeneity in trials which differ not only in terms of practitioners, but also in terms of dose and type of manual intervention (such as Swedish body massage, knee manipulation, or specific therapeutic approach), comparison group, and type of OA (knee or hip) [39]. Although trials may make a joint-specific distinction of including people with knee or hip OA, another potential confounder in examining effectiveness in trials is the extent of OA, as people may have multiple joints involved that include both the hip and knee. Compared to knee OA, recently, more high-quality trials have investigated hip OA and evidence is conflicting.
Two recent trials have evaluated manual therapy provided by physical therapists. Abbott and colleagues [40] investigated the use of manual therapy alone, exercise alone, or the combination of manual therapy and exercise in comparison to a usual care group of participants with knee or hip OA. They found that both exercise and manual-therapy-alone groups showed significant improvements in total WOMAC score at 9 weeks and 1 year, and the combination group did not show additional benefit [40]. In contrast, a trial by Bennell and colleagues [41••] compared manual therapy plus other physical therapy strategies (home exercise, education, and assistive device prescription) to a sham therapy which included the use of ultrasound and application of an inert gel to the affected joint. In this highly controlled trial, both the treatment and sham groups experienced significant benefits in reported pain and physical function following treatment, and there were no significant differences between groups in objective physical measures. This finding calls into question the effectiveness of these techniques in hip OA and demonstrates the need for more highly rigorous trials in this area.
Bracing
A common form of bracing in knee OA is the use of a valgus brace which is designed to offset joint load in people who have OA in the medial compartment of the tibiofemoral joint and is recommended in clinical practice guidelines [42]. A recent meta-analysis of six trials concluded that valgus bracing had small to moderate effects on pain and function, and the effect depended on study design. Optimal practices for bracing are not known as instructions on wearing the brace varied widely in these studies and there were differences in type of brace (off the shelf versus custom fit) used [43]. Lateral wedge insoles are another treatment used to treat medial knee OA. A recent meta-analysis of 12 trials showed no statistically or clinically important improvement in pain in higher quality studies and using a control condition of a neutral insole [44]. The findings do not support the use of lateral insoles as a treatment for medial knee OA.
TENS
Transcutaneous electrical stimulation (TENS) has been a recommended treatment for pain relief in OA in many clinical practice guidelines [14, 37]. This involves applying electrodes to the skin using a small battery-operated unit that provides low-voltage electrical stimulation to the painful area. A meta-analysis of 18 trials in 2009 was inconclusive in its evidence to support TENS. The trials included in the analysis were small and of variable quality. Similar, modest improvements in pain were found across all treatment groups, those receiving TENS, a sham condition, or usual care [45]. A large clinical trial involving 224 participants was conducted in 2014 to determine the added effects of TENS for knee OA in combination with standard rehabilitation treatment which involved group education and exercise program. Participants were randomized into three arms: TENS + standard treatment, sham TENS + standard treatment, or standard treatment alone. In all groups, pain and physical function on the WOMAC improved after 6 weeks of intervention and was maintained for 24 weeks. Across the groups, 33–42 % reached clinically important improvements on physical function on the WOMAC (the primary outcome measure) and the active TENS + standard treatment group had the lowest percentage of people who reported this difference [46]. Thus, the current evidence does not support the use of TENS as a treatment in knee OA.
Assistive devices/technology
Assistive devices such as walking aids are widely recommended by many clinical practice guidelines to offset joint load in OA. In addition, other assistive devices that may reduce stress on joints may also be prescribed. There is not a strong evidence base to support these practices, although device prescription is common in clinical care. Some of these practices may be subsumed under a description of education in OA studies, but trials would be required to better understand how these devices are used and their effects.
Activity pacing
Activity pacing is the practice of regulating daily life activities or routines to meet goals [47]. This is a behavioral technique that is often taught in rehabilitation and also can be taught by psychologists. Activity pacing has been a source of conceptual confusion. In a survey of health professionals, 81 % said they teach pacing to patients, but there was not a consensus about what it entails [48]. One common form of activity pacing is called time-based activity pacing in which people are taught to adhere to a time schedule of activity and rest in order to not overdo activity which can lead to symptom flares, or to avoid long periods of rest which may also lead to symptom flares. Recently, a trial was conducted to examine time-based activity pacing delivered by occupational therapists for people with knee or hip OA. Participants were randomized into two conditions of time-based activity pacing (tailored based on physical activity and symptom patterns collected by an enhanced physical activity monitor), general activity pacing (similar instruction without the tailored feedback), and usual care. No significant group differences were found in pain or physical function; although lack of findings may be due to the brevity of the intervention (three sessions) or the low level of symptoms in the sample [49].
Physical rehabilitation interventions for OA can vary significantly. Though some patients may experience diminished pain and improved function from therapies, recent studies evidence overall effects to be minimal at best. As the OA phenotype is also inclusive of psychological components, cognitive behavioral treatment approaches rooted in psychology may appropriately address these concerns.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is a form of psychotherapy whereby negative patterns of thinking, behavior, and emotional responses are challenged and restructured, thereby facilitating behavior change [50]. CBT has been incorporated into interventions that address pain and sleep disturbances, two common symptoms of OA that adversely impact function and mental and emotional well-being [51, 52•].
Cognitive behavioral therapy for pain (CBT-P)
CBT that targets pain (CBT-P) may include strategies ranging from problem solving and pain coping skills training (PCST), to goal-setting and relaxation [53]. A randomized controlled trial (RCT) comparing CBT-P to general practice primary care showed no differences between the two groups with regards to pain or function [54]. Additionally, a negative impact of the CBT-P intervention on pain self-efficacy was noted, possibly due to the participants becoming more conscious of their pain and behaviors and how pain has been impacting their lives.
In some instances, a single therapeutic strategy from CBT-P, most often PCST, has been integrated into OA management interventions, resulting in small to medium treatment effects. For example, a nurse practitioner-led program found that PCST reduced pain intensity and interference while improving pain coping and self-efficacy for controlling pain; only small effects were observed [55]. In a RCT of an automated, internet-delivered PCST program, medium effects were documented, with the intervention group showing significant improvements in pain and self-efficacy compared to an assessment-only control group [56]. Current evidence for CBT-P and use of individual strategies such as PCST is equivocal at best and likely to result in small to medium treatment effects.
Cognitive behavioral therapy for insomnia (CBT-I)
CBT has also been used to treat insomnia (CBT-I) and may involve strategies such as sleep restriction, sleep hygiene education, stimulus control, or cognitive therapy for insomnia [57]. A study by Smith et al. [51] showed that CBT-I significantly improved objective and subjective sleep and insomnia compared to a behavioral desensitization placebo. These improvements were comparable to the meta-analytic, post-treatment effects of benzodiazepine receptor agonist sedative hypnotic [58]. Overall, CBT-I appears to improve sleep-related issues in OA.
CBT-P combined with CBT-I (CBT-PI)
A combination of CBT-P and CBT-I (referred to as CBT-PI) has been investigated. A large-scale RCT compared CBT-PI to CBT-P and included an education control group that was provided non-directive pain and sleep education [59]. Severity of insomnia and pain decreased and arthritis scores (including pain and function) improved in all groups. Adding the insomnia component to the CBT-P improved insomnia ratings compared to CBT-P and education only. CBT-P did not improve pain ratings, however, but did have indirect positive effects on sleep efficiency [52]. In a secondary analysis, regardless of group, those who showed improvements in insomnia symptoms at 2 months reported long-term, sustained sleep quality benefits at an 18-month follow-up [60]. These improvements in sleep were associated with long-term improvements in pain severity, arthritis symptoms, and fatigue. Current evidence for use of CBT-PI shows promise in addressing symptoms of pain and insomnia simultaneously.
Community-based and self-management programs
Community-based and self-management programs for arthritis shift the primary responsibility of wellness maintenance and disease management from the healthcare system to the community and to individuals with OA. A systematic review that primarily included community-delivered OA exercise programs showed that individuals who participate in such programs show more favorable outcomes related to function and health-related quality of life compared to those who only receive standard of care (i.e., attend scheduled consultation visits with a healthcare professional) [61]. Adverse outcomes have rarely been reported, aside from potential mild musculoskeletal discomfort resulting from increased exercise, suggesting that these programs are a safe non-pharmacological option for self-management of OA.
There are a number of arthritis-specific community and self-management programs available for individuals with OA (Table 1). They vary widely in terms of duration, intensity, cost, key components, instructor qualifications, targeted arthritis issues, and evidence supporting their effectiveness in improving health outcomes. For instance, the Arthritis Self-management Program (ASMP), typically taught by peers with arthritis, is a self-help education program for persons with arthritis and has been shown to significantly improve self-efficacy, health behaviors (e.g., communication with physicians), fatigue, anxiety, and depression [67]. The ASMP has multiple delivery formats ranging from in-person group sessions to a self-study toolkit. In contrast, a lesser researched program, the Arthritis Foundation Aquatic Program (AFAP), includes aquatic exercise offered by trainers at a recreational facility (e.g., YMCA), and focuses on endurance, joint range of motion, and aerobics. Participants have shown improvements in functional fitness, strength, flexibility, and quality of life [62–64]. Providing patients with a gamut of community-based program options will help to ensure that a patient can find the most suitable, sustainable program given his or her unique lifestyle and needs.
Emerging treatments and approaches
Combined patient/provider intervention
One recent OA clinical trial (n = 300) combined a telephone-based OA intervention for patients who received their care within the Veteran Affairs healthcare system with an intervention designed to assist primary care providers to tailor evidence-based treatments using clinical practice guidelines [78]. The telephone-based intervention was delivered by a trained health educator over a 12-month period and focused on weight management, physical activity, and pain coping skills training. The provider intervention was done by monitoring upcoming clinic visits and providing patient-specific recommendations in the electronic medical record to the primary care providers prior to the visit. The recommendations were provided based on an algorithm to help determine what treatment strategy may be reasonable for the primary care provider to consider and consisted of non-pharmacological options. Small improvements were found in the WOMAC, particularly in physical function (10 % improvement) at 12 months compared to a usual care group. Interestingly, while providers recommended more non-pharmacological interventions for participants in the intervention group compared to the control group, patients did not use them at a higher rate than usual care. The lack of utilization may be due to difficulty to access these treatments as they often require more frequent travel to the medical center. This intervention provides an innovative approach to help integrate evidence-based non-pharmacological treatments into clinical management for OA.
Investigation into CAM treatments
Complementary and alternative medicine (CAM) refers to health practices developed outside of mainstream conventional medicine [79]. Non-pharmacological CAM therapies are extensive and inclusive of practices and treatments such as yoga, tai chi, qi gong, chiropractic or osteopathic manipulation, meditation, prayer, massage, acupressure, and acupuncture. Race and ethnicity appear to influence specific CAM therapy preferences. For instance, a large cross sectional study of over 9000 adults found increased use of acupuncture amongst Asians (15.8 %), increased use of prayer amongst Blacks (56.3 %), and increased use of massage amongst Whites (29.4 %) [80]. However, rather than race or ethnicity, the greatest predictors of CAM-use was presence of a chronic disease [80].
Within OA populations, CAM use is becoming increasingly prevalent, yet due to the highly individualized nature of many CAM treatment programs; large controlled studies are not typical. Interestingly, Shengelia and colleagues [81] completed a systemic review of studies testing the use of tai chi, yoga, acupuncture, and massage to manage OA and found these therapies to be effective in reducing pain and stiffness and improving physical functioning. However, when comparing CAM to exercise and conventional therapies, CAM typically underperforms [82]. For example, in evaluating the effectiveness of acupressure compared to isometric exercise and a control group, Sorour, Ayoub, and Abd El Aziz [83] found that although acupressure decreased pain the most, isometric exercise was the most effective at reducing stiffness and improving physical functioning amongst all treatment groups.
Despite the minimal treatment effects that CAM produces, Lapane and colleagues [82] observed in a study of more than 2000 patients with knee OA, that nearly 50 % of patients reported CAM use either solely or in conjunction with conventional medicine. Consequently, providers should query patients in-depth about use of CAM so as to avoid unintended negative interactions with additionally prescribed treatments, be prepared to respond to patient inquiries regarding CAM options, and recommend optimal therapies. Providers and patients may find CAM providers through the government website https://healthfinder.gov (type CAM into the search box).
Technology-based interventions
The use of technology-based interventions, particularly those that involve telehealth, or web or mobile device delivery, is increasing in popularity due to its versatility, cost-effectiveness, and potential to extend the reach of OA treatment beyond in-person contacts. Evidence supporting technology-based interventions, however, is still in its infancy compared to that which is available for more traditional delivery methods. Many published investigations of technology-based interventions are in the feasibility or efficacy testing phases. For instance, Clayton and colleagues [84] proposed a feasibility trial of a multifaceted intervention that includes a physical therapist-led educational module paired with use of a wrist-worn activity tracker and follow-up phone check-ins to increase physical activity engagement in persons with knee OA. Similarly, Bossen and team [85] are preparing an “E-Exercise” intervention comprised of visits with a physical therapist and an interactive website to improve exercise engagement in persons with lower extremity OA. Other innovative approaches under investigation include use of smartphone technology, such as an intervention prototype proposed by Ortiz et al.[86] that supplies customized TENS, electrical muscle stimulation, and iontophoresis therapy, activated by a smartphone application, and delivered through a Bluetooth-enabled knee orthosis. Although promising, substantially more evidence is required before the use of technology-based interventions for treatment of OA is empirically justified.
Conclusions
OA is a complex disease that requires interdisciplinary team support to manage pain, changes in function, and psychological correlates. Non-pharmacological treatments are the foundation of optimal OA disease management. Despite many effective interventions and strategies, non-pharmacological approaches are not well-integrated into clinical care. As the US population continues to age and experiences multiple chronic comorbidities including OA, providers need to be prepared to holistically manage OA by promoting patient self-care practices, recommending engagement in physical fitness and maintenance of healthy weight and nutrition. Furthermore, increased provider familiarity with available rehabilitative and integrative health services will likely lead to increased patient utilization and the creation of more opportunities to further evaluate efficacy of desired clinical outcomes.
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Murphy, S.L., Robinson-Lane, S.G. & Niemiec, S.L.S. Knee and Hip Osteoarthritis Management: A Review of Current and Emerging Non-Pharmacological Approaches. Curr Treat Options in Rheum 2, 296–311 (2016). https://doi.org/10.1007/s40674-016-0054-7
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DOI: https://doi.org/10.1007/s40674-016-0054-7