ACOFP Blog

2021 Namey/Burnett Preventive Medicine Writing Award Submission
By Alexis O’Connell, OMS-III, Alabama College of Osteopathic Medicine

For years we have been telling our patients to move more. With the COVID-19 pandemic leading to wide-spread shutdowns, stay-at-home orders and quarantine protocols, employees are working from home and finding new and even more sedentary daily routines than ever before.

As a result of this physical inactivity, metabolic and musculoskeletal complications may lead to worsening of these chronic diseases and increase the number of physically disabled people in the years to come. As primary care physicians, we need to continue to motivate our patients with practical recommendations to incorporate ways to stay healthy from a distance and mitigate unintended side effects when they arise.

Venturing Out

Older adults that may have never exercised before are beginning to venture outdoors, finding low impact exercise such as walks and bike rides around their neighborhoods as a welcome respite from the confines of their homes. An unfortunate symptom of repetitive exercises—especially among those with excess adiposity and insulin resistance—are osteoarthritis flare-ups in the hips, knees and hands, which can limit mobility and discourage subsequent physical activity. Working with patients to reduce the inflammation and oxidative stress that are responsible for the underlying triggers of these flare-ups through conservative nonpharmacologic and pharmacologic treatments can be helpful for managing these concerns.

New Osteoarthritis Guidelines

In 2019, the American College of Rheumatology and Arthritis Foundation published guidelines for osteoarthritis (OA) of the hand, hip and knee. In this report, strong direction was given for clinicians to recommend continued walking and cycling, as well as aquatic exercise training and balance and stabilization techniques, which could secondarily reduce the risk of falls by strengthening weak core and gluteus muscles.

Weight loss of >5% of body weight showed significant symptomatic and functional benefits and even more improvement with further reductions in weight up to >20%. Tai Chi and Yoga were strongly suggested due to the benefits of the relaxed gentle movements and deep breathing, which additionally showed improvement of depressive symptoms. Use of a cane, braces and orthotics were recommended as well.

Less obvious recommendations were also advantageous, such as self-efficacy programs and cognitive behavioral therapy. This is due in large part to the relationship between pain, quality of life, functional capacity and mood, and the beneficial impact of discussing these factors in an organized session (even via virtual/online). With the streamlined and universal adoption of telemedicine visits recently, consider following up with patients with joint pain in a virtual visit to monitor their progress. A simple 5–10-minute discussion may be the difference in improving their outcomes.

Of course, usual care such as the mainstay pharmacologic treatment of oral NSAIDs is the standard; however, the new OA guidelines also included a strong recommendation for intra-articular glucocorticoid injections and the incorporation of ultrasound guidance for hip injection placement. Interestingly, long-term treatment of Acetaminophen has no difference to placebo. Also, among the central acting agents including pregabalin, gabapentin, SSRIs, SNRIs and TCAs, only Duloxetine showed evidence of success in treating osteoarthritis.

A few treatments were strongly recommended against—including TENs unit, hyaluronic acid injections, which failed to show clinical benefit in relation to saline. In addition, IL1 Receptor Antagonists, TNF inhibitors, PRP, Stem Cell, and Prolotherapy injections, glucosamine, chondroitin sulfate, bisphosphonates, hydroxychloroquine, methotrexate, colchicine and vitamin D were advocated against universal use.

Dietary Factors

Included in the evidenced-based approaches to dietary modification for sufferers of osteoarthritis are the following: limiting total and saturated fat, aggressive lipid-lowering strategies and incorporating oily fish and flaxseed as a source of EPA, as well as foods rich in Vitamin K, like Brussels sprouts, spinach, kale and broccoli.

Lowering dietary saturated fats and lowering total cholesterol and LDL with statins or via intake of plant stanols and sterols—including those found in walnuts, almonds, and pistachios—can be chondroprotective. EPA can decrease production of pro-inflammatory mediators like eicosanoids, ROS, NO, and cytokines and increase anti-inflammatory modulators like resolvins. Vitamin K supplementation in those who are deficient can result in less joint space narrowing. These practical modifications can result in long-term rewards.

Reassuring Patient Concerns

It can be reassuring for patients to know that their worsening joint pains after jumpstarting a new exercise routine is common and can be easily addressed. Creating a game plan that works for their individualized needs and scheduling a telemedicine follow-up can be a great way for patients to feel like their pain isn’t going unnoticed, that they are not alone during this incredibly isolating time and to discuss any issues that may arise along the way.

For additional details, please refer to the following articles:

• Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, Gellar K, Harvey WF, Hawker G, Herzig E, Kwoh CK, Nelson AE, Samuels J, Scanzello C, White D, Wise B, Altman RD, DiRenzo D, Fontanarosa J, Giradi G, Ishimori M, Misra D, Shah AA, Shmagel AK, Thoma LM, Turgunbaev M, Turner AS, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). 2020 Feb; 72(2):149-162. doi: 10.1002/acr.24131.
  
• Thomas S, Browne H, Mobasheri A, Rayman MP. What is the evidence for a role for diet and nutrition in osteoarthritis? Rheumatology (Oxford). 2018 May 1;57(suppl_4): iv61-iv74. doi: 10.1093/rheumatology/key011.