Osteoarthritis Management in Obesity
Tuesday, April 19, 2011
Osteoarthritis is one of the most disabling and painful conditions attributable (in part) to excess weight. Once established, osteoarthritis significantly reduces quality of life and mobility, often precipitating further weight gain and posing an important barrier to weight management.
A panel of experts (The Ottawa Panel) has now released a comprehensive set of evidence-based clinical practice guidelines for the management of osteoarthritis in overweight and obese patients, published in PHYSICAL THERAPY.
The recommendations are based on an extensive review of published articles with strict application of quality criteria to rate the strength of evidence (A, B, C, C+, D, D+, or D-) as well as experimental design (I for randomized controlled trials and II for nonrandomized studies).
Clinical significance was established by an improvement of ≥15% in the experimental group compared with the control group.
The panel decided on a total of 79 recommendations: 36 positive (21 grade A and 15 grade C+) – all were of clinical benefit.
Overall the data supports the recommendation that physical activity combined with (mildly restrictive) diet programs are beneficial for pain relief, functional status, strength and quality of life.
Although 5% reduction in body weight reduced pain and functional status, this degree of weight loss was insufficient to slow disease progression.
Both aquatic and land-based aerobic exercise were shown to be more effective in reducing pain than home-based strengthening exercises. On the other hand, land-based exercise performed in a gym that included strength, aerobic, stretching, and range-of-motion training was more effective in reducing pain compared with a home-based strengthening exercise program.
These benefits of exercise are independent of any changes in body weight and the authors suggest:
“The significant improvements in QoL among study participants with OA who were obese or overweight may be a reflection of mental health and social benefits associated with the participation in physical activities. Physical activity promotes psychological well-being by reducing feelings of fatigue, depression, and anxiety and improving self-esteem, confidence, concentration, and mental awareness. The social benefits of participation in physical activity include a reduction in the sense of isolation and loneliness, improved social networks and social capital, and increased community connectedness and cohesion.”
Importantly, the authors also note that:
“To the knowledge of the Ottawa Panel, there is no conclusive evidence on the most appropriate methodological scale to apply for OA and obesity research. The use of BMI, waist circumference, and body weight as valid indicators of successful weight loss in individuals with OA is debatable because these measurements do not discriminate between lean and fat body mass.”
Nevertheless, the panel recommends:
“…reducing weight prior to the implementation of weight-bearing exercise to maintain joint integrity and to avoid joint disease and dysfunction.”
How this weight loss is best achieved (and maintained) of course remains open to debate.
Importantly perhaps, the readers should also note that the review did not look at surgical studies, where patients generally experience substantially greater weight loss than with ‘diet and exercise’ alone.
I would certainly love to hear my readers’ experience of the impact of diet and exercise and/or weight loss on their osteoarthritis symptoms. What worked? What didn’t?
AMS
Edmonton, Alberta
p.s. the issue of osteoarthritis and obesity will be an important topic at the upcoming 2nd National Obesity Summit in Montreal next week.
Brosseau L, Wells GA, Tugwell P, Egan M, Dubouloz CJ, Casimiro L, Bugnariu N, Welch VA, De Angelis G, Francoeur L, Milne S, Loew L, McEwan J, Messier SP, Doucet E, Kenny GP, Prud’homme D, Lineker S, Bell M, Poitras S, Li JX, Finestone HM, Laferrière L, Haines-Wangda A, Russell-Doreleyers M, Lambert K, Marshall AD, Cartizzone M, & Teav A (2011). Ottawa Panel Evidence-Based Clinical Practice Guidelines for the Management of Osteoarthritis in Adults Who Are Obese or Overweight. Physical therapy PMID: 21493746
Tuesday, April 19, 2011
I come from a long line of obese, diabetic arthritics. I will turn 60 next spring. I always have been fairly active–bicycling and weight lifting mainly–and still am a recreational skier. I am female and my BMI is 31 or so. Over the past year I’ve developed noticeable stiffness in my knees and hips which is especially concerning as both my mother and maternal grandmother had both knees replaced due to arthritis and probably would have needed hip replacement if they’d lived long enough.
I follow a very low carbohydrate diet (less than 20 grams/day except on rare occasions). Four months ago I cut back my calorie consumption by about 10 percent, and I’ve lost 5 percent of my body weight. At the same time I began practicing Bikram yoga, which I now do 3 or 4 times a week. This is a very vigorous form of yoga and is very demanding. However, I now have absolutely no pain or stiffness anywhere. I’m often though not always the fattest person in the yoga studio, but with those results, who cares?
Tuesday, April 19, 2011
A bit of history first on how I became a 34 year old with Stage IV OA. I was an obese child and 240 pounds by my freshman year of high school. I first tore my ACL at 15 in 1993 and had it replaced when I weighed 200 lbs (my lowest HS weight). This was the beginning of the end for my left knee. The patella tendon graft did not hold and at 18 I had it replaced again with a cadaver graft, I was 240 pounds. Over a year later Serratia Marcesans was found in my tibia around the pin. Debridement and subsequent complications ensued. My weight went from 240 to 345 over the next several years. In 2000 I had a medical ah-ha moment, while not knee related, it was powerful enough for me to act upon. Over the next several years I lost a total of 185 pounds on my own, no diet plan, just eating better (and yes less) and walking. Sometimes 6-7 miles a day for the first 100 pounds and then significantly less due to increasing pain until I reached my happy weight in the fall of 2004. Alas all that walking wore away the ligament compromised by infection and my OA took hold as my joint became unstable again.
Two years into maintenance my Orthopod at the time told me I would lose my mobility by time I was 40 if I didn’t fix the chronic instability. The wear and tear of the joint would only hasten the decline of my cartilage of my cartilage he told me. I said okay to a 3rd ACL attempt (another cadaver graft at 155lbs)…. and 6 weeks later it came out due to Staph. I’m not over it.
Since then I have had more complications including a graft that left bone granules calcifying in my soft tissue. Painful. I no longer exercise but despite this have been able to continue to maintain my loss (although at 165) with no exercise. There has been no significant regain and honestly fear of more pain is a powerful motivator. I walk (with a lidocain patch) but nothing organized and nothing at the gym. While I know I should it’s hard to get out of my own way when I often depend on a cane to get around. I need help getting off the toilet occasionally and need to sit down to put on a pair of pants. Again I am 34.
I am clearly to young for a TKA but with OA in all 3 compartments every step is painful. Every step pops and grinds and reminds me of the weight I used to carry and yes my nosocomial infections. I’m hoping to be surgery free for 5 years (last knee surgery was in 2009 for a total of 11) and do not doubt that if I was still 345 pounds or even 240 pounds I would not be mobile. OA has taught me that you do not need exercise to maintain a loss or to even lose weight. I firmly believe that weight loss is a good 85%-90% what we put in our mouths… And while I know that my OA is the result of all sorts of things, surgical trauma, infection, ACL tears, my morbid obesity and crappy genes… I take comfort in the fact that I have done as much good for myself as possible. My right knee tells me that. Hopefully when I am 60 it will still work just as well as it does now.
In the meantime. Ice is my best friend. 🙂
Tuesday, April 19, 2011
Dr. Sharma,
Bilateral hip replacements was the ONLY thing that helped reduce (read: eliminate) any of the pain for me. Diet, exercise, pain killers and, most importantly, physiotherapy were all virtually useless – particularly physiotherapy. They (Physiotherapists) don’t add any value to the process at all, except to ensure personal job security.
Tuesday, April 19, 2011
First of all, I have a question. Is osteoarthritis a genetically inherited condition? Most of my family have had OA, and have eventually had hips/knees replaced because of it. I was a very active teenager, 5′ 9″ and 175 lbs, swimming, biking, and roller skating for hours at a time, several days a week. I also did a lot of falling, and when I fell, I always landed on my right knee for some reason. When I was 34, after another fall and a swollen knee, I was diagnosed with OA (I had dieted my way up to 350 lbs). I’m now 57 and looking at knee replacements (both knees are almost bone-on-bone). I had a VBG in 1997 as my then-nurse practitioner said no surgeon would replace my knees at my then-weight of 350 lbs (she lied). I lost 80 lbs, but vomited so much that the stapling came undone and I gained back everything I lost and a few more pounds as well (in 2006, I weighed 396 lbs). I’ve somehow managed to get down to 375 lbs (don’t have a clue how I did it or how I’ve stayed there for 3 years), but my OA is worse, which is why I’m looking at knee replacements in the near future. My right knee is still worse than my left knee, as far as pain and swelling go, but according to my orthopedic doctor, both knees are about the same as far as the amount of cartilage left and wear on the bones themselves. The year that I was 80 lbs lighter didn’t make much difference in how my knees felt when I had to walk or stand for any length of time – they still hurt, they still swelled, pain meds still didn’t work very well.
I have other mobility issues that my GP refuses to address – severe lower back pain that radiates into my hips and thighs. All she can say is eat less, move more, it’s calories in/out and refuses to see that all the dieting, diet drugs, and WLS haven’t worked to make me weigh less, and in fact, have made me fatter than I would have been if I hadn’t ever done any of that in the first place. She says I need to exercise, but refuses to prescribe anything stronger than relafen for pain, and relafen doesn’t even begin to touch the back pain I have when I have to stand or walk for more than a minute or two. So I refuse to go back to see her, I’m afraid to look for another doctor because I’m tired of hearing the Nightmare on ELMM Street lecture. At least I don’t get that from my orthopedic doctor, and he’s willing to replace my knees whether I lose weight or not.
So, for me, personally, no, weight management hasn’t done a thing to help my osteoarthritis, and in fact, everything my doctors have recommended has made it worse.
Tuesday, April 19, 2011
I have lost approx. 40 + lbs. over the course of having two hip replacements d/t OA. The Right hip was replaced in 2004 and for a number of reasons I was not as mobile, as previously, which meant that I wasn’t anywhere near the places where one buys junk food and such!! I was preparing grocery lists for someone else to shop with – I was staying at her house (no stairs). I truly lost my taste for junk – I’d always eaten well, but obviously too much. The first 30 lbs. came off in the two months following the surgery. I had the left hip replaced in 2007 – much faster convalescence, but I still worked to keep up my new habits. The total now is over 40 lbs. and I have re-trained myself to eat better. I’m 64 and will be retiring later this year and will have more time to do more regular exercise during the day. I now weigh the least I’ve weighed in 40 yeasrs!! I know that has helped with the stress on knee joints – I don’t believe I need replacements there. Overall, the OA is worst in my hands and wrist joints and can, at times, be quite debilitating – for example the twisting action of using one’s right hand to lift food from a plate and into one’s month can be very painful. I do use Tylenol for pain and I have #3’s if I need them, but I try to manage without.
I know that my aches and pains would be a lot more severe if I were still carrying that extra weight.
Tuesday, April 19, 2011
My mother was always on the heavy side, despite the fact that she speed skated and rode her bike long distances in her youth. A picture I have of her, standing on what looks like Fifth Ave. in New York, shows a short somewhat stocky woman in a lovely tailored suit and a jaunty hat. I am her only child, born when she was 43. By the time she was 50, she was pretty much housebound with OA in both her hips. I believe the OA led to her weight gain, rather than that the weight gain exacerbating her OA. I remember that she used to go for pool therapy, but not long. She also had OA in at least one knee. My mother had a partial hip replacement, but it never made a difference in her mobility. She is gone now, so I can’t ask her why the operation was so spectacularly unsuccessful.
My aunt (my mother’s sister) also suffered from severe OA in both hips. She too had surgery, but from my vantage point, it didn’t seem to make much difference. She too was housebound, although having a husband with a car to take her out made her life much more pleasant than my mother’s who had neither husband nor car.
My aunt’s grand-daughter, who’s a yoga instructor, also has OA in her hip, diagnosed in her early thirties. So far, she has avoided surgery, but has gained some weight.
I have always gained weight easily. Although my mother was a health food fanatic long before anyone else we knew and only kept nutritious foods in the house, we both struggled with our weight. I am also very short (like my mom). For me, the difference between a BMI of 25 and a BMI of 30 is less than 20 pounds. At my height and with my propensity to gain weight easily, it might as well be 100 pounds. And guess what? When I was in my early thirties and maybe 20 pounds less than I weigh today (and at a fairly decent weight), I was diagnosed with OA of the hip. I had my first hip replacement at 47 (I’m now 54), followed by a revision about 8 months later due to complications. I have never been able to find out whether the surgeon intentionally made my hip tight and restricted my range of motion to prevent dislocation, but the result is that I can do very little exercise other than walking. I also have a very fragile back (1 discoidectomy when I was 25 and not particularly overweight) and two subsequent ruptured discs that were not treated with surgery. And now my left knee, which took the brunt of my hip recovery, is so bad that stationary biking or the elliptical trainer just make the pain and stiffness much much worse. I am scheduled for a knee replacement at the end of this year.
What do I do in the meantime? I walk and do yoga with a yoga therapist. Swimming is also out in that it stirs things up in my back, my knee and my hip. I have just discovered “urban poling”–it’s like cross-country skiing on the sidewalk with no skis and just the poles. This seems to not make any part of my body scream or cringe. I feel OK poling…hopefully…so far.
I have to laugh when people say that all you have to do is lose weight to lose the pain. It’s just not that simple.
Oh and physiotherapists…I have reserved a special place in hell for them. Within a couple of months of my first hip surgery, I started actually getting worse and was less and less able to walk, even on crutches. The five (count ’em, five!) physios I saw all assured me that everything was fine and that I was just making a slower than usual recovery. When I saw my surgeon, the first thing he made me do was stop the physio–it was actually making me worse. As I mentioned above, I had to have a revision.
OA has not made my life, my mother’s, my aunt’s or my cousin’s a walk in the park.
Wednesday, April 20, 2011
I’ve weighed between 180 and 220 (at average height) since I was 11, but that’s probably not very relevant to this story.
When I was 19, I was in a nasty roll-over car accident where I was thrown half way out of the car (the seat belt held me in) and the car ended up on its side with my midsection trapped under the chassis. In addition to internal injuries, my left hip was dislocated and broken in two places. I healed quickly afterwards, but twenty physically active years later, I was diagnosed with trauma induced osteoarthritis in my left hip. By the time the condition was diagnosed, I’d been subconsciously compensating for it for years. Once I knew how bad it was (when the doctor saw the first X-ray, she immediately said ‘you need a hip replacement’), the hip went downhill fast. Physiotherapy provided temporary relief, but within a year, my mobility had decreased noticeably and within two years, I could only walk around two blocks without major pain, and less than a kilometer without my hip giving out.
That wasn’t an acceptable level of mobility for me, so I decided to get the hip replacement at that point, even though I wasn’t walking with a cane, and most people who knew me weren’t aware that anything was wrong. I didn’t try to lose weight. I’d researched the condition and learned that the kind of injuries I had pretty much always result in a ruined joint after around 20 years – for thin people as well.
I’m almost two years post-hip replacement now. I was very young to have it done, and it’s not surprising that I was way, way ahead of the curve when it came to recovery. I was done with the walker by the time I left the hospital and was off the strong pain killers and back to work after 2 weeks. I only needed a cane for three months. It took probably 6 months for me to get back to the level of mobility I had before the surgery (walking). However, it was a year before I could run without a limp. Running still feels awkward, actually, but I can walk all day with, at worst, minor pain. I’m not as fit as I was two years before the operation, but I’m getting to the point where my body really seems to want to move more. I’m feeling more and more like myself.
When I was recovering from the hip replacement, pilates and water aerobics were invaluable – especially pilates. The physical therapy exercises helped a lot, too. Obviously, building my left abductor muscles back up was the most important thing (they’d been sliced through in the operation, and those are the muscles that allow you not to topple over to the opposite side when you walk). I really needed that added core strength too, because the new hip doesn’t move the same way or have the same range of motion as the original one. Keeping my lower body aligned and moving smoothly and (superficially) symmetrically takes extra strength and puts strain on my back and my core muscles. If I don’t exercise (and stretch!) regularly, I start to have problems with soreness.
I guess my point is, don’t wait until you’re really messed up to have joint replacement surgery. Get it done before the damaged joint effects the rest of your body, your mobility, and your feeling of physical competence. The worst thing about the bad hip and the hip replacement is that they’ve eroded my old ‘I can do anything’ attitude. I’m starting to branch out again, physically, but after four years of thinking everything was going to hurt, my default attitude on physical activity has gone from ‘that looks fun!’ to ‘what will happen if I wrench my hip or fall on it?’ I’m not used to being scared of hurting myself. I can’t imagine how much worse that feeling would be if I’d let the hip thing drag on and on rather than getting it taken care of. And, my fast recovery was because my body was still fairly fit. I hadn’t allowed myself to become inactive.