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Barriers to Osteoarthritis Management

Despite relative uniformity in clinical guidelines, the care Australians receive for osteoarthritis is variable and often divergent from the guidelines, according to Martin Basedow (University of South Australia) and his research team.

This situation seems somewhat consistent across physiotherapists, practice nurses, pharmacists, and general practitioners. To shed light on the barriers to guideline-consistent osteoarthritis treatment, Thorlene Egerton (University of Melbourne) recently published an interesting systematic review and synthesis.2 Analysing input from clinicians (largely general practitioners and practice nurses), Edgerton identified four themes serving as potential barriers to osteoarthritis management and no themes serving as enablers. Here we outline those themes and take the next step of proposing evidence-based answers to those barriers.   
(1) The disposition that osteoarthritis is an inevitable part of aging and not serious. While osteoarthritis is certainly common and increasingly so with age, a minority of people have it, even among the elderly.3 It is not inevitable. Osteoarthritis causes more disability in walking, stair climbing, and housekeeping than any other disease.4 It is serious. 
(2) Lack of awareness of the guidelines.  Broadly speaking, clinical guidelines recommend exercise and weight loss as the first-line treatments. Second-line treatments include selfmanagement support, education, and finally NSAIDs. If these measures fail, joint replacement with more exercise occurs.3,4 Respondents in the eight studies reviewed by Edgerton and colleagues commonly reported skipping nonpharmacological treatments or dramatically reducing how they are implemented. 
(3) Doubts about treatment effectiveness. The feedback reported here actually revolves around patient adherence. Clinicians note that patients often do not request education on osteoarthritis and they do not adhere to recommendations for exercise and weight loss. The evidence suggests this is partially true. Advice for weight loss and exercise does not regularly achieve important lifestyle changes. However, the research notes that medium to high-intensity counselling does achieve medium to large lifestyle changes - especially where diet is concerned.5-13 The most successful interventions involve multiple training and counselling sessions spread over weeks or even months. 
This highlights the role of outpatient physiotherapy and exercise physiology. The standard practice model in these professions involves moderate to high-intensity training directed in part toward changing patients’ self -care patterns. Advanced Physiotherapy, in particular, serves as a good referral destination in osteoarthritis. Our blending of physiotherapy and exercise physiology gives patients access to joint rehabilitation as well as formal weight loss and nutrition programs. 
The fact of the matter is that when physiotherapy adds exercise to the plan of care as a first-line treatment, patients get better and healthcare spending goes down.14 Physiotherapy reverses the progression of osteoarthritis.14   
(4) Dissonant patient expectations. The comments here revolve around a greater need for community education and patients insisting that osteoarthritis be treated as an inflammatory condition. We’ll do our part. Our emails and social media reach thousands monthly. We offer patient education material on a wide range of subjects and will continue to offer education on guideline-consistent management of osteoarthritis. 

1. Basedow M, Williams H, Shanahan EM, Runciman WB, Esterman A. Australian GP management of osteoarthritis following the release of the RACGP guideline for the non-surgical management of hip and knee osteoarthritis. BMC Research Notes. 2015 Dec; 8 (1): 536. 
2. Egerton T, Diamond LE, Buchbinder R, Bennell KL, Slade SC. A systematic review and evidence synthesis of qualitative studies to identify primary care clinicians' barriers and enablers to the management of osteoarthritis. Osteoarthritis and Cartilage. 2017 May 1; 25 (5): 625-38. 
3. Englund M, Turkiewicz A. Osteoarthritis increasingly common public disease. Lakartidningen. 2014;111 (21):930. 
4. van Dijk G, Dekker J, Vennhof C, et al. Course of functional status and pain in osteoarthritis of the hip or knee: a systematic review of the literature. Arthritis Rheum. 2006; 55: 779-85.
5. Wluka AE, Lombard CB, Cicuttini FM. Tackling obesity in knee osteoarthritis. Nature Reviews Rheumatology. 2013 Apr;9(4):225. 
6. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the US bone and joint initiative. In Seminars in Arthritis and Rheumatism. 2014 Jun 1 (Vol. 43, No. 6, pp. 701712). WB Saunders. 
7. Buchbinder R, Richards B, Harris I. Knee osteoarthritis and role for surgical intervention: lessons learned from randomized clinical trials and population-based cohorts. Current Opinion in Rheumatology. 2014 Mar 1; 26 (2): 138-44. 
8. Patel N, Balady G. The Rewards of Good Behavior. Circulation. 2010; 121: 733-735.
9. Twardella D, Merx H, Hahmann H, et al. “Long term adherence to dietary recommendations after inpatient rehabilitation: prospective follow up study of patients with coronary heart disease.” Heart. 2006; 92 (5): 635-40.
10. US Preventive Services Task Force. Behavioral counseling in primary care to promote a healthy diet: recommendations and rationale. AJN The American Journal of Nursing. 2003 Aug 1; 103(8): 81-92. 
11. McCarron D, Reusser M. “Cardiovascular Risk Reduction Dietary Intervention Trial.” Drug Benefit Trends: 2000; 12 (5): 42-48.
12. West JA, Miller NH, Parker KM, et al. A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization. Am J Cardiol. 1997; 79: 8-63.
13. Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med. 1998; 158: 1067-1072.
14.  Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. Journal of Orthopaedic Trauma. 2006 Nov 1; 20 (10): 739-44. 


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