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Physiotherapy should be first-line treatment for hip and knee OA, not surgery

Photo: Australian Physiotherapy Association
Osteoarthritis, or OA, is the most common form of arthritis, affecting more than 2.1 million Australians.

Defined as the progressive dysfunction of the entire joint, including bone, ligaments, cartilage and muscles, the symptoms associated with OA may include pain, stiffness, swelling and instability - irrespective of the cause - which may lead to impaired function.

The traditional course of action for an individual with hip and knee OA is a visit to the GP, analgesia, and possibly imaging of the affected joint. For persistent pain, the patient is usually referred to a specialist, where further interventions, such as injections or surgery may be offered.

Surgery has become an extremely common method of treatment, with as many as 100,000 knee arthroscopies being performed per year at a cost of over half a billion dollars.
In recent years though, surgery to manage hip and knee OA has been under increased scrutiny, primarily due to the significant increases in surgeries being carried out nationally.

“To some extent, this is to be expected given our aging population, however, of primary concern is the number of individuals being offered surgery prior to having engaged in any non-surgical interventions, which have proven to be effective,” says Australian Physiotherapy Association member Matthew Williams.

“In the NSW Osteoarthritis Chronic Care Program for example, up to 70% of participants on the waiting list for knee surgery had no conservative management except for medication.

“Ultimately, joint replacement surgery is a very good option for individuals with end stage hip and knee OA, but only once all other treatment options have been exhausted, as, like with any surgical procedure it is not without its risks.”

Some of the possible negative consequences of surgery include infection, fracture, blood clots, dislocation, among others.

Not only has the number of knee operations soared, there is increasing evidence that surgery simply isn't’ necessary, particularly in early stages of OA.

“In several high quality research trials examining the benefit of knee arthroscopy on knee OA patients, those participants who underwent a sham procedure, where patients were under the impression that they had received a knee arthroscopic procedure, but only received surgical site wounds, versus a genuine knee arthroscopic procedure, which may include the removal or repair of injured cartilage and other techniques, proved to have a similar effect on their pain,” Mr Williams says.

“Therefore, improvements derived from the procedure could be largely influenced by placebo, whereby any perceived benefits from the operation are attributed to the participants belief that the intervention has reduced their pain, rather than any influence of the operation itself.”

Mr Williams says first-line management of hip and knee OA should include exercise in the form of a tailored strengthening program provided by a clinician with expertise in the area such as a physiotherapist, with the addition of some aerobic-based activity such as walking.

“If this is too challenging initially, then other forms of exercise such as water-based activity may be considered.

“Weight loss where appropriate should also be included as a core management strategy as well as education about the nature of osteoarthritis and the benefits of an active approach to an individual’s care.

“Appropriate analgesia should then be considered in addition to these first-line treatment strategies as necessary.”

However, each type of analgesia carries side effects which has the potential for serious health consequences.

Which is why new guidelines have reinforced the importance of exercise and weight loss as first-line management of the condition.

The guidelines strongly recommend against the use of previously implemented interventions such as opioid analgesic medication and knee arthroscopy among other often invasive and expensive interventions.

“Physiotherapy via strengthening the muscles that support the affected joints and employing strategies to lose and maintain weight loss,  have significant impacts on reducing pain, enhancing function and improving quality of life for individuals with hip and knee OA,” says Mr Williams.

“Studies have shown that individuals who lose 5% of their body weight in combination with a strength-based program can reduce their pain by 30%, and those that lose over 10% of their body weight can reduce their pain by 50%.”

Over recent years, musculoskeletal conditions including hip and knee osteoarthritis have been gaining increasing exposure, due to the realisation of the significant impact it has on the individual sufferer, as well as the far reaching implications for our health and economic systems. 

Nevertheless, Mr Williams says more education is necessary to reduce the high numbers of potentially unnecessary operations.

“Given that a large proportion of OA sufferers are progressing to hip and knee surgery without having been exposed to any conservative management options, further exposure and education to the public and our medical professionals regarding the effectiveness of non-surgical treatment options is essential.”

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Nicole Madigan

Nicole Madigan is a widely published journalist with more than 15 years experience in the media and communications industries.

Specialising in health, business, property and finance, Nicole writes regularly for numerous high-profile newspapers, magazines and online publications.

Before moving into freelance writing almost a decade ago, Nicole was an on-air reporter with Channel Nine and a newspaper journalist with News Limited.

Nicole is also the Director of content and communications agency Stella Communications (www.stellacomms.com) and a children's author.