Teaching osteoarthritis (OA) patients self-relaxation, rational use of pain medications, goal-setting, and other self-management techniques to can improve pain and self-reported functional level, according to a new study appearing in the March issue of the Journal of Rheumatology.¹

"These findings are in accord with previous trials of self-management with positive outcomes in patients with OA, and, therefore, broader implementation of this intervention in the primary care settings is warranted," conclude researchers led by Peter H. Heuts, MD, of the Rehabilitation Foundation Limburg in Hoensbroek, the Netherlands.

In the 21-month study, patients aged 40 to 60 years with OA of the hip(s) and/or knee(s), 149 patients supplemented standard care from their physician with six, 2-hour self-management classes, while 148 patients received no additional care other than that provided by their primary care physician. At 3-month follow-up, patients in the self-management group had an average decrease in knee pain of 0.67 points on a visual analog scale (VAS), versus virtually no change in the group assigned to normal care. The intervention group also showed a 2.46 improvement on the Western Ontario and McMaster (WOMAC) Universities OA Index, compared with a deterioration of 0.53 in the controls. Similar results were observed in the patient-specific functional status score. Differences between groups were even more pronounced after 21 months, although the authors point out that the data indicate improvements in knee pain as assessed by VAS, but not hip pain.

Given by physiotherapists, the cognitive-behavioral, self-management program comprised information on OA, instruction on how to take initiative in personal health and functioning, and adequate goal-setting in combination with self-incentives as motivators to optimize activity level. Participants learned about the rational use of prescription medication and assistive devices and received self-relaxation training. They also learned problem-solving techniques that helped resolve challenges of daily living and self-diagnostic skills to better identify changes in their health status. The intervention group received information on community resources and better use of available health care services.

"Our self management program was performed by physiotherapists in a primary care setting; therefore, the conclusion can be drawn that there are possibilities for implementation in the general health care settings for a broad population," they write. "For family doctors and physiotherapists, this opens up treatment possibilities for the enormous groups of patients with OA."

 

Findings affirm clinical experience

Orthopaedic surgeon Joseph Guettler, MD, of William Beaumont Hospital in Royal Oak, Michigan, agrees that such programs are feasible and beneficial.

"It's very routine in my practice to send patients who have signs and symptoms of OA to a therapist for a few visits to get home instructions and a home stretching and strengthening program," Dr. Guettler tells CIAOMed. "The new findings confirm what I feel is already working in my practice."

Despite the recent evidence linking COX-2 inhibitors and risk for cardiovascular disease, these and other analgesic drugs should also play a prominent role in management of knee OA, he observes. "We as physicians have known for a long time that these drugs carry certain side effects, but they do play a role in OA management in addition to a home exercise program," Dr. Guettler says.

"I think some of the reluctance [to encourage self-management] might come from the old school mentality that you either live with [OA pain] or replace [the joint], but in my practice, I seek to offer patients different options," he says. "I tell my patients that I will bridge the gap and try to keep them away from the joint replacement surgery for as long as possible."

For most middle-aged OA patients, "my main tools are exercise and nonsteroidal anti-inflammatory drugs (NSAIDs). I am quite liberal with glucosamine chondroitin supplements, and sometimes I augment with injectable viscosupplementation and [recommend that] patients embark on a home program."

Reference:

Heuts PH, de Bie R, Drietelaar M, et al. Self-management in osteoarthritis of hip or knee: a randomized clinical trial in a primary healthcare setting. J Rheumatol. 2005;32:543-549.