Osteoarthritis is often considered and managed as a single disease when it is, in fact, a whole series of different combinations of pathology and pain1 which require different management approaches. It is therefore important to decide ‘what osteoarthritis’ we are trying to manage before we start.
When we assess an OA case (Module 2) we are seeking information which can be assembled and used to guide management. The more information that we can obtain through a good assessment the easier it is to choose management options which are most likely to be successful.
There are two obvious components of the disease that we need to look at
- Pain
- Pathological changes
Clinical cases may be described as ‘mild’, ‘moderate’ or ‘severe’. But what does that mean? Often the judgement is based on the influence of just one component of the disease, such as acute pain, advanced pathological changes, imaging results or severely compromised mobility. The description suggests that all aspects have been considered but that is not usually the case. Pain is the usual driver of a severe judgement, but it can be transient and reversible unlike pathological changes. It is useful to judge these different systems independently (see later – Tri-Sector Assessment) to obtain a more accurate measure of the complete problem and to identify exactly what needs to be addressed whether this is immediately in the short term or whether a more patient, longer-term approach is indicated. How the problem is likely to respond, or progress needs to be predicted to allow the creation of an effective and sustained management plan.
1.1 Consider Pain
When we assess pain, we should not just be looking at severity but also duration or longevity. These give us different bits of information about the type of pain present and its underlying cause. Severe pain requires rapid action to identify its source and if it can be diminished. Longer duration chronic pain should be assessed for the presence of sensitisation, often complicating many chronic pain cases. This requires a more patient approach to management using longer term analgesia to affect an improvement. So, it is important to define what pain we are dealing with and how it is likely to respond to our management. This is important when considering how quickly we should expect to see change and ensure that our general expectations for success are based on this. Many perfectly sensible management approaches are abandoned too early because they appear to have not abolished the pain quickly enough. This is unrealistic when chronic sensitised pain is present which may have to be managed for months to obtain a full response. So, we need to have the correct expectations to appreciate successful management outcomes.
1.2 Pathological Changes
Module 1 explained how OA pathology is dynamic and changes throughout the course of the disease. It is important to establish what types and range of pathology are present to allow targeting by management in affected joints. Adiposity although not a direct pathological consequence of OA has such an influence on the pathological progress and clinical impact of the disease that it must be considered in assessment. OA pathology is often considered irreversible. That is certainly true at the current time for established articular cartilage pathology. However, if we consider the various pathologies which combine to produce the clinical disease that we recognise as osteoarthritis we can see that many of these can be slowed or indeed reversed, which can have a huge impact on the clinical problems posed by the disease (Table 1). These areas are also targets for treatment using a systematic and progressive management process.
Table 1 Reversibility of Pathological Features
| Pathology | Ability to Reverse | Management |
| Articular Cartilage | Very Limited | Almost impossible to reverse when well established. Better chance in early disease |
| Sub-chondral Bone | Limited | As above |
| Synovial Fluid | Possible | Can be modified by reducing synovitis and can be supplemented by short acting lubricants |
| Synovial Inflammation | Possible | Can be controlled by anti-inflammatories and certain intra-articular medications |
| Joint capsule fibrosis | Possible/ preventable | Can be modified by intra-articular medication but also by joint manipulations |
| Peripheral Sensitisation | Reversible/ Preventable | Can be reduced by long term nociceptive signal reduction |
| Central Sensitisation | Reversible/ Preventable | Can be reduced by long term nociceptive signal reduction |
| Muscle Wasting/weakness/ proprioception | Reversible/ Preventable | Physical therapy can either prevent or be used to restore muscle function |
| Adiposity | Reversible/ Preventable | Dietary management to prevent and dietary control to reduce |
1.3 Objectives in Management
- Modify pain to reduce severity
- Consider duration and act to reduce chronic pain and sensitisation
- Identify the main pathological features and target the ones that can be reduced or reversed
- Reduce adiposity and maintain a lean body weight.
- Consider if physical therapy would help manage pain and either restore mobility or prevent loss of muscle