Welcome to the fourth installment of our blog series. This month we will be taking a look at knee osteoarthritis (OA) , and what we as Occupational Health Physiotherapists can do to help patients, specifically in relation to work.
Osteoarthritis (OA) affects millions of people across the UK and can significantly affect working lives. Knees are the most common area to be affected with OA, due to the knee joint taking a lot of force and stress because of its load-bearing function. The most common symptoms include pain, swelling, and crepitus, and the knee can give way due to weak surrounding muscles. Pain at night is also common, and can be a sign of more advanced arthritis, as can locking of the knee, reduced knee extension with increased knee valgus or varus, and a fixed flexion deformity.
To gain more insight into the patient’s problems the use of clinical outcome measures can be key. The Knee injury and osteoarthritis score (KOOS) questionnaire assesses patient’s opinion about their knee and associated problems. It has been used widely in research and clinical trials and can used as an effective tool to guide the assessment over their symptoms and difficulties. This outcome measure is intended for knee OA, ACL, meniscus and chondral injuries. The outcome measure can be used short term or over years, its validity is based upon a multitude of research and expert opinion.
Thinking away from the knee?
Many OA patients’ pain is chronic and therefore we should be careful in the language we use just as we are with all chronic pain conditions. Pain is a complex area and with knee osteoarthritis it can be both nociceptive related to the pathology and also can be centrally mediated pain. We must take this into account with our assessment and treatment approach. There are some great information booklets available for patients to read at the British Pain Society website which may help your patients understand there pain in simpler terms.
Communication skills are key and it is important to let the patient tell their story and avoid interrupting them. It is important to use positive language and look to see what the patient can do themselves to help improve their condition. Many times patients come in telling me they have been to see their GP and have been told they have got ‘wear and tear’ and told nothing can be done. This presents more of a challenge and we have to work hard to undo this belief which doesn’t happen overnight. Hence, this should involve a multi-factorial approach to help alleviate symptoms allowing the employee to stay at work which we know can help improve their physical and psychological wellbeing. Patient empowerment is key.
What should employers do?
It is important that if employees are struggling with work that they are advised to speak to their line managers in the first instance to see if any adaptions can be made. Osteoarthritis can cause a “physical impairment with substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities” (Equality Act, 2010); employees are protected under the Act which means employers are legally required to make reasonable adjustments. If employees are reluctant to raise concerns with their line managers, then they can approach their Occupational Health departments for advice and support. Often employees are afraid of approaching their employers and frequently ignore the issues until they are unable to cope anymore. According to Donovan et al 2016 early intervention from a physiotherapist at work demonstrated a 37% reduction in absence. This is why IPRS Health believe early intervention to be so key. As a company with years of Occupational Health experience we know that employers have a strong drive to help their staff remain healthy and at work. Particularly as 20% of organisations have increased their focus and attention on health and wellbeing at work with 41% of companies discussing it at board level as a fundamental strategy. We believe if patients work collaboratively with their employers to manage their condition they will achieve optimal outcomes.
What can your patients do to help themselves whilst at work?
Prioritising, planning and pacing throughout the working day
As we have discussed already OA can be a painful condition, and so work place advice can help. Focusing on one task at a time, prioritising the workload and spreading out more challenging tasks with easier tasks inter-spaced between them are all good tips to reduce the load throughout the day.
Stress and anxiety
If, stress and anxiety seem to be the main driver of a patients pain you may want to consider an onward referral for potential psychological support. Cognitive Behavioral Therapy can help patients dealing with any emotional or psychological issues. However if stress and anxiety is only a low partial contributor and you do not feel requires an onward referral, we should feel confident as physiotherapists to provide empathy and reassurance in these situation, as well as practical advise in how to combat some of these issues. The benefits of exercise in reducing stress are widely researched and we are well within our scope as physiotherapists to advocate this as a means of improving mental, as well as physical health.
As mentioned the stress busting effects of exercise have been well researched in the past, but in recent years have taken a few steps forward. There is a growing body of literature that suggests it’s down to a process called ‘Adult Neurogenesis’. This is a process that takes place in the brain and in particular the stem cells in the subgranular zone of the dentate gyrus of the Hippocampus. Adult neurogenesis is the process by which our brains create new neurons. Exposure to stress can reduce the effects of this neurogenesis process. Particularly the hormone cortisol which down regulates serotonin, it can affect the rate at which new neurons are produced and this has effects for many things like the ability to remember things, as well as the ability to take on new information.
The research has strongly demonstrated (initially in mice and more recently in humans!) that exercise has the direct opposite effect on the hippocampus and adult neurogenesis. When you exercise at a moderate intensity for you it promotes neurogenesis in the hippocampus. This has the effect of reducing stress!
Micro-breaks during the work day
Taking 30-60 second micro-breaks every 15 minutes which can include the opportunity to sit when needed can also help to moderate load. Latest research recommends that ‘your next posture is your best posture’ which means the patient should avoid staying in one posture for a long period time. There is no one right or wrong way to sit so promoting movement variability is key.
What can the patient do at home?
The National Institute of Clinical Excellence (NICE) Guidelines (updated 2014) recommends that exercise should be the core treatment for osteoarthritis. A randomised controlled study by Knoop et al (2015) found that improved muscle strength in the leg was associated with reduced pain levels with patients with knee osteoarthritis. Another study by Bezalel et al (2010) concluded that a group education programme and home based exercises significantly improved functional ability and pain reduction in patients with knee osteoarthritis. Patient education is key as some patients believe that exercise will lead to more ‘wear and tear’ when in fact the opposite is true. Among people with knee osteoarthritis, land-based therapeutic exercise provides short-term benefit that is sustained for atleast 2–6 months after cessation of formal treatment. If exercise can be sustained, so can the benefits!
Functional Restoration Programmes
A functional restoration programme (FRP) can be a great way to tackle knee OA in the workplace. An FRP involves pain education and the use of coping strategies, alongside a 6-week group exercise plan aimed to target the specific limitations affecting their functional mobility. A recent participant in IPRS Health’s FRP in Dagenham who had moderate knee OA showed a significant improvement in his subjective and objective outcomes post FRP.
Use of Technology
For those patients who like to use apps, the ESCAPE Pain programme recently launched its new app, with 16 exercises to help users with pain management and to better manage their conditions. Mike Hurley, CSP member, professor of rehabilitation sciences and originator of the ESCAPE Pain programme, said: ‘Thanks to the ESCAPE Pain app anyone with chronic knee or hip pain can benefit from the programme, regardless of where they live. It is a tool that’s ideal to support people to exercise safely and regularly in their own home.’
IPRS Health also recently launched the IPRS Health app, which is designed to provide our patients with self-help and educational material (including versions of this blog) to help them self-manage both musculoskeletal and mental health conditions. The app and associated website (myiprshealth.com) contain articles, videos and downloads along with a symptom checker and is available to all our patients.
Weight loss is a core treatment for osteoarthritis (NICE guideline CG177) as, obviously, reductions in body weight reduce joint loads, particularly in the knees and hips, leading to reduction in osteoarthritis pain. Bliddal et al (2014) have cited a study which showed that in overweight and obese older adults with knee OA, it was estimated that every pound of weight lost resulted in a four-fold reduction in the load exerted on the knee per step during daily activities, which appeared to be clinically meaningful. GPs are often able to refer patients on to local weight management schemes run by councils, or within their own practices, that provide dietary and weight control advice.
It is advisable to encourage patients that smoke to cease smoking as, in addition to the general health benefits, this can also help prevent knee pain and further cartilage loss in osteoarthritis, as evidenced in the study by Amin et al (2007).
Surgery is an option for end stage/severe knee osteoarthritis patients, however should always be carefully considered and only when function and quality of life are severely affected, where conservative methods have failed.
It is important to be aware that patients who demonstrate greater number of pain sites and higher levels of preoperative pain, higher levels of catastrophising, depression and anxiety, and poorer levels of preoperative function are more likely to continue to suffer with post-operative persistent pain (measured at 3 months post op by Lewis et al, 2015). This highlights the need for a holistic biopsychosocial approach. Surgery is only recommended as a last resort after all other interventions have been explored. The latest guidelines from the EULAR group on osteoarthritis at the knee propose 11 recommendations based on evidence and expert opinion (EULAR 2012).
Thanks for taking the time to read this post. I hope you have found it useful and interesting.
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As a parting gift here are some of the useful links discussed throughout the blog and references can be provided at request.
IPRS Health Physiotherapist