Sorting out the joints


knee pain

We need to raise awareness of the immense burden caused by poor bone and joint health, promote preventative measures and support self-care

Bone and joint-related conditions, namely osteoarthritis and osteoporosis, are widespread in the community. According to the Australian Institute of Health and Welfare (AIHW), approximately 2.2 million Australians have osteoarthritis. Indeed, in 2017-18 it affected 12% of females and 6.8% of males.

In the same period, 924,000 Australians were affected by osteoporosis and, similar to osteoarthritis, it is more common among females than males; 6.2% of females have osteoporosis compared with 1.5% of males. The prevalence of both conditions increases with age.

Without a doubt, osteoarthritis and osteoporosis have a significant impact on individuals and their families, not to mention the burden on the health system. As such, messages promoting the importance of looking after bone and joint health are incredibly important.

Understanding osteoarthritis

Osteoarthritis is considered the most common chronic joint disease in Australia and a leading cause of pain, disability and early retirement. Indeed, as Australia’s population ages, the cases of osteoarthritis are expected to soar.

In response to these projections, there are increased calls for greater focus on reducing obesity and increasing physical activity as preventative measures. There’s also demand for better self-care support for those living with osteoarthritis.

Franca Marine, national policy and government relations manager at Arthritis Australia explains, “There have been major changes in our understanding of osteoarthritis. In particular osteoarthritis is no longer viewed as an inevitable process of wear and tear. Instead, osteoarthritis is now thought to be the result of a joint working extra hard to repair itself. In addition, inflammation has been identified as a major contributor to the development and progression of the disease.

“The leading risk factors for osteoarthritis are excess weight and joint injuries, in particular sports injuries. Around half of all cases of osteoarthritis of the knee are thought to be due to excess weight, while an additional one in five cases can be attributed to joint injuries—in particular, injuries to the anterior cruciate ligament.”

Consultant pharmacist Jenny Gowan explains that identifying cases of osteoarthritis is about finding out what’s going on with the person and referring appropriately.

“We need to ascertain whether it’s an acute or persistent pain and where the pain is; whether it’s superficial or deep. We can ask how long they have had the pain and how big of an impact is it having on their life.

“Is it a stinging or burning pain? Ask if they’re experiencing pins and needles, which is an alarm bell. If there are numb feet and numb fingers, then it’s not just arthritis. Often any sort of pain is tagged as arthritis, but it may not be. We really need to get an accurate diagnosis of the cause of pain.”

Managing and preventing osteoarthritis

Prevention of osteoarthritis should focus on modifiable risk factors. Marine says excess weight is the most important modifiable risk factor associated with the development and progression of osteoarthritis, especially osteoarthritis of the knee.

“Forty-five percent of the osteoarthritis burden in Australia is attributable to overweight and obesity. Achieving and maintaining a healthy weight is an important step, both to reduce the risk of developing osteoarthritis and as a strategy for managing the disease.

“Every extra kilogram of weight you carry puts four kilograms of extra pressure on your knees, so losing weight can literally help to reduce the pressure on your joints. For overweight people with established osteoarthritis, weight loss of between 5–10% of their body weight can result in significant pain relief, and this can improve mobility, physical function and quality of life. Greater weight loss achieves even larger improvements in symptoms,” advises Marine.

In addition, physical activity, while avoiding joint injuries, is critical to strengthen the muscles that support the joint and beneficial for better health in general.

Marine says, “Exercise has been shown to achieve improvements in knee pain and physical function comparable to those reported from non-steroidal anti-inflammatory drugs.

“There isn’t just one particular exercise or activity that is recommended for all people with arthritis. People should choose an activity that they enjoy and that is convenient for them. Low-impact exercises, with less weight or force going through your joints, are usually most comfortable.”

Examples of low-impact activities include:

  • walking;
  • aquatic exercise, such as hydrotherapy (with a physiotherapist), swimming or water-based exercise classes;
  • strength training;
  • Tai chi;
  • yoga and pilates;
  • cycling; and
  • dancing.

Ms Gowan says, “For people who are overweight or obese and have hip or knee osteoarthritis, losing weight will help release that pressure on the knees. They may need referral to a dietician, counselling or medication to assist with this.

Latest osteoarthritis guidelines

The Royal Australian College of General Practitioners (RACGP) first developed guidelines for the non-surgical management of hip and knee osteoarthritis in 2009.

Last year the guidelines were updated to reflect the latest evidence in the field of treatment and decrease the overreliance on medication and surgery.

While the latest guidelines discourage the use of some traditional therapies, Gowan says cognitive behaviour therapy in conjunction with exercise, heat packs and possibly walking aids are recommended.

“Walking aids are particularly useful for older people to help them with mobility and balance and prevent falls.

“Massage can be an adjunct to lifestyle measures and TENS machines also have some supportive evidence, which can be offered through pharmacy.

“Physical therapies that don’t have a lot of evidence to support them include laser, ultrasound, braces, footwear, taping. Certainly, there’s a lack of high quality evidence to support these and so the guidelines can’t make recommendations on them,” Gowan advises.

Indeed, the guidelines discourage the use of opioids for people with knee and/or hip osteoarthritis and cannot recommend either for or against the use of paracetamol or topical non-steroidal anti-inflammatory drugs.

“The guidelines are unable to make recommendations on paracetamol so my advice is to ask the patient. If they feel it’s helping, well it might be and if they don’t feel it’s bringing any benefit, then it’s probably not!” says Gowan.

“You can firstly try paracetamol as-necessary, then suggest the therapeutic levels and assess whether it’s making any difference or not. Try for a short period and stop if it’s not effective. We do need to be aware, however, that some people are likely to double up; they might take Panamax and they might also get Panadeine Forte on prescription, causing a double up of paracetamol.

“With regards to non-steroidals, these were the mainstay of treatment for years and while they have a little bit of evidence I’d suggest a trial for a short period only—providing comorbidities do not exclude them.

“In practice I would also suggest a trial of topical non-steroidals for a short period of time, as long as there are no contraindications—such as warfarin,” Gowan advises.

“Evidence for glucosamine and chondroitin is very low. However, if people say they find it’s useful and it’s doing no harm—other than being a cost to them—then it’s probably okay. The same goes for fish oil. You need a very high dose to achieve an anti-inflammatory effect and the side effect is reflux. We haven’t got very good evidence for low dose fish oil, but there is a little evidence to support using a high dose.

“The other interesting complementary medicines for which some evidence is emerging are boswellia serrata extract, pine bark extract, curcumin and methylsulfonylmethane. However, further studies are needed for evidence-based recommendations.

“Anecdotally, I have had a lot of patients coming back for curcumin as they find it really useful, but they have to get the dose right so pharmacists need to give them the accurate dose.”

Professor David Hunter, co-chair of the Guideline development working group for the RACGPs, tells the AJP, “According to a recent quality of care study, pass rates for various aspects of osteoarthritis management are poor. More specifically, most patients are not offered appropriate advice regarding education, exercise and weight loss.

“Alongside this, the pharmacologic recommendations are also typically inappropriate. Paracetamol and opioids are no longer recommended in the guidelines, yet they form the majority of what patients are recommended for analgesia.

“With regards to the role of the pharmacist, many of the aspects that are routinely recommended in the guidelines can be advocated for by a pharmacist in addition to not advocating for treatments that don’t provide therapeutic benefits.”

Raising awareness of osteoporosis

Unfortunately people are still not taking their bone health seriously enough—despite the fact it can lead to fractures and severely reduced quality of life.

Greg Lyubomirsky, CEO of Osteoporosis Australia, says, “Osteoporosis remains under-diagnosed and under-treated because bone health is not yet a high enough priority.

“This can change with active investigation of patients with risk factors for osteoporosis and investigation of adults over 50 years following a minimal trauma fracture. In 2019 there will be over 165,000 fractures due to poor bone health, so we know we can do better.

“Pharmacists have a vital role to play in raising the issue of bone health with customers. This is particularly helpful in people who have certain conditions or take medications that may be impacting their bone health.”

Conditions that may impact bone health include:

  • coeliac disease;
  • rheumatoid arthritis;
  • hyperparathyroidism;
  • diabetes;
  • glucocorticoid steroid use (longer than 3 months and greater than 7.5mg/day); and
  • lack or calcium or vitamin D deficiency.

“Pharmacists can identify patients post-fracture (minimal trauma fracture) who may be on pain medication but have not been investigated for any potential underlying cause of the fracture. These patients should be encouraged to speak with their GP about a follow up check on their bone health.”

To help bring greater awareness to the issue of bone health, Osteoporosis Australia and the Garvan Institute of Medical Research developed Know Your Bones, an online self-assessment tool (accessed via www.knowyourbones.org.au).

Pharmacy can recommend this useful tool to patients older than 50 years of age, which provides a report for users that can be taken to their doctor, if required.

Supporting healthy bones

“The practical advice that pharmacy staff can give customers is that preventative measures, such as calcium, exercise and vitamin D, are essential to maintaining bone health,” Mr Lyubomirsky says.

“The best way to achieve this is by sustaining a healthy lifestyle and by avoiding lifestyle risk factors, such as smoking, alcohol and low levels of physical activity.

“There are plenty of positive steps people can take to help support their bone health, but one of the most important is ensuring adequate calcium intake. Calcium is the major building block for bones; it gives them their strength.

“In Australia it is recommended adults have 1000mg of calcium per day, increasing to 1300mg per day for women over 50 years and men over 70 years. Dietary calcium is the preferred source of calcium intake. When dietary intake is low, a supplement in the range of 500–600mg per day is recommended.”

He says calcium and vitamin D remain the key focus for maintaining healthy bones. However, protein is also important to maintain muscle strength and to assist with good balance, especially in the elderly.

“For those people who have been diagnosed with osteoporosis, pharmacists play a key role in explaining their osteoporosis medications to them, This should be done both in terms of the role of medication in reducing fracture risk in the mid to long term, as well as the importance of taking medication as directed to obtain the full benefit.

“While compliance with medication is an issue in many chronic disease areas, pharmacists are a trusted voice in delivering this important information which ultimately leads to better patient outcomes.”

He adds, “Often the issue of ongoing medication compliance and/or adherence is not consistently covered in general consultations with patients, therefore it is an ideal opportunity for pharmacists to reinforce the importance of taking medication long term during the dispensing of scripts.” •

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