So you have arthritis. So what?
“There is not much you can do for me, buddy. The MRI said I had the back of an eighty year-old.” My new patient, a man in his mid-forties, sat across from me, eyes locked with mine, lips pursed, eyes and his arms crossed in a proud show of defiance—a little odd since he was the one to come and see me. I sighed internally, strained to maintain a buddha-like smile on the outside, and nodded. This was about five years ago. I was a new graduate physiotherapist and eager to help, yet oddly feeling like I was already in the middle of a confrontation. He had shown up reluctantly, having been ‘encouraged’ to come by his wife.
A Common Story
This situation, and many like it, aren’t that uncommon for physiotherapists. People show up already convinced they can’t be helped. Following a diagnosis such as arthritis, many patients internalize their condition and seem to make it a part of their identity, allowing a false belief that they are irreparably disabled to take over. This often presents as a massive barrier when trying to help someone get from a life of pain and disability to one of health, happiness, and unhindered participation in life. The most unfortunate fact is that most of this trouble often stems from a single incident.
Typically, there is an episode of pain followed by a worried visit to the doctor. Maybe the person was active and healthy, but started to notice something getting sore at work, while working out, playing sports, or as they moved through a day of errands. Following a quick physical assessment with the doctor, scans are ordered, findings come back, and then there is an excessively grim interpretation of x-ray and MRI findings. Yeah, you have arthritis. Pain now will just have to be a part of your life. It gradually snowballs from there. As fear of further pain and damage sets in, people limit themselves from getting back to normal and end up in a downward spiral of pain and less involvement in the activities that bring them joy.
“I also have it in me knees, me neck, me hands, and me shoulders,” the mid-forties guy made sure to let me know, his arms still crossed and firmly hugged into his chest, leaning back into his chair. I was working home in Newfoundland at the time.
Our Views on Osteoarthritis Have Dramatically Changed
In this post I will focus on osteoarthritis, the most common form of arthritis and what people usually mean when they use the term ‘arthritis’ alone. For decades, osteoarthritis has been poorly diagnosed and managed. Typically, if you went to the doctor with a sore joint, you left the office with an osteoarthritis diagnosis, a prescription, and maybe some vague advice on pain management and staying active. We know today that this is absolutely not how you diagnose and manage joint pain. Most health professionals are getting better at preventing and curbing this, but the effects of these poor interventions, even from many years ago, still reverberate today as a common issue for patients seen in clinics all over.
I’ve mentioned this before, and I will likely say it many times again: x-ray and MRI findings of degenerative joints, even if riddled with degeneration, are one of many, many factors that may be contributing to pain or arthritis. They are not helpful for most common aches and pains. Given that most ‘abnormalities’ we have seen in the past, including rotator cuff tears, bulding discs, and degenerative joints are actually normal signs of aging. For example, 85% of all people will have signs of knee degeneration on an x-ray (2), even if there is no knee pain present. Up to 98% (!!!) of adults with no neck pain will have MRI findings of disc degeneration (3). Informing a patient that they have such findings but failing to explain that they are normal and not always associated with pain causes harm through increasing psychological distress and perceived disability. We then move and exercise less, or with greater caution, which leads to increased pain and further loss of function.
First, is Your Pain Even Arthritic Pain?
I’ve seen many cases of ‘osteoarthritis’ that have turned out to be cases of misdiagnosis. The confusion begins when someone gets an x-ray or MRI that shows degenerative changes in their joints. Not all pain in the presence of degenerative change findings is necessarily osteoarthritis pain. Fact (1-3). The hallmark characteristic of an osteoarthritic joint and what separates it from asymptomatic wear and tear is inflammation.
Osteoarthritis is Latin for ‘bone’ (osteo), ‘joint’ (arth) and ‘inflammation’ (itis). The thing is only about half of people with signs of degenerative change on their x-ray or MRI develop notable symptoms of inflammation (4). This is because there are several other factors that likely contribute to the development of inflammation in a joint. For many, findings of degenerative change in the joints are most often signs of slow, long-term age-related changes that happen to everyone, a lot like how we get grey hair and wrinkles. Inflammation is not always present in these situations. Pain and stiffness in your knees, hands, back and neck is not always due to inflammation and arthritis.
So how do you know? Osteoarthritic pain, the result of an inflamed joint, tends to be worse in the hours surrounding bedtime, sometimes eases with light activity but is easily aggravated by over-activity, and usually includes symptoms of heat, redness, a throbbing sensation, swelling, or a significant loss of function. Pain that does not fit this pattern is typically mechanical in nature (i.e. the result of muscular imbalances, poor form, or repetitive-movement sprains and strains), or less often due to postural stress or long-term nervous system changes.
The good news is that these other possible causes often respond well to exercise when it is properly prescribed. A health professional trained in the management of musculoskeletal conditions can help you to determine if your pain is due to osteoarthritis or not. I’ll be honest, its hard not to feel a little self-righteous as a physiotherapist when you take years of pain away from an ‘arthritic’ neck by having a patient do a couple of exercises, or when knee pain from supposed-osteoarthritis disappears on the spot with some foam rolling and movement re-education.
So, even though might you have signs of wear and tear on your x-ray, they are often just incidental findings of normal age-related wear and tear and are poorly linked to pain. There are many other possible causes to your pain besides arthritis, and many of them tend to respond very well to conservative management.
Exercise Still Improves Osteoarthritis
Okay, what if it really is osteoarthritis? Let’s say your knee swells, it often hurts just to walk across the room, and sometimes you can’t even straighten or bend it all the way. Guess what? This usually responds well to exercise too4. Exercise also helps to alleviate osteoarthritis symptoms in your hips (5), your hands (6), and so on.
What if it is really bad? What if you did all the right things, but still really do need surgery? I think back to when a friend of mine had hip pain that just wouldn’t go away. It had been going on for months. She consulted with me once, then saw a massage therapist, then another physiotherapist, and then a chiropractor. Everyone seemed to have a different opinion, which only made things worse. She bounced between practitioners with little relief until she eventually ended up back with me. As per usual, I earnestly suggested that she get to the gym or pool and start exercising it. “The doctor thinks its from years of work, and my chiro thinks my labrum might be torn too” she said. I responded, “Okay, so what do you think is going to have to happen once you have surgery? Once they cut through muscles, fascia, get down to the joint and ‘clean up’ what they find in there?”
A brief silence.
“…I’ll have to exercise it.” I did my best not to look too smug. Sometimes as patients we get so caught up in worry, mixed messages from healthcare providers, and being in pain that common sense and practical advice can fall to the wayside. Not many patients get to skip post-operative rehabilitation, which involves of a series of visits to the physiotherapist for exercise prescription. So why not just try to start now? Often surgery waiting lists are months, if not years, long, and while you wait exercise has been shown to help to alleviate symptoms of arthritis and improve function, even when it is so severe that joint replacement surgery is required (7). What about after surgery? Emerging research so far shows that pre-operative exercise improves post-operative outcomes, particularly in the short term after surgery (8). Even in the worst situations, there is usually a way to get the patient to start moving and to improve their quality of life, whether they eventually go for surgery or not.
As for my friend, she got moving. I provided her with some direction and she went to the gym and started exercising her hip along with the rest of her body. Shortly after, her pain got better and stopped bothering her. Often the simplest solution is the one that works the best.
Be More Than a Diagnosis
A diagnosis of osteoarthritis should be a signal to move more, not less. There is more to pain than just what you see a scan. That scan is attached to an entire person. If you are in pain, don’t be afraid to exercise. Understand that exercise is usually the solution, and it comes with the countless other benefits that I’m sure you’ve heard of in the past. If you feel stuck, find help; look for someone who can help you navigate through pain and inflammation and provide strong advice on how to overcome it. Get moving. Do not let one scan determine the rest of your story.
Mark Austin BKin MScPT ACMT
1. Loeser, RF. Age-Related Changes in the Musculoskeletal System and the Development of Osteoarthritis. Clin Geriatr Med. 2010 Aug;26(3):371-86.
2. Bedson, J & Croft, PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord. 200 Sep 2;9:116
3. Okada, E. et al. Disc degeneration of cervical spine on MRI in patients with lumbar disc herniation: comparison study with asymptomatic volunteers Eur Spine J. 2011 Apr; 20(4): 585–591.
4. Fransen, M. et al. Exercise for osteoarthritis of the knee. 2015. Cochrane Database of Systematic Reviews
5. Fransen, M. et al. Exercise for osteoarthritis of the hip. 2014. Cochrane Database of Systematic Reviews
6. Østerås, N et al. Exercise May Benefit Hand Osteoarthritis. J. Rheumatol. 2017 Oct 15.
7. Moyer, R. The Value of Preoperative Exercise and Education for Patients Undergoing Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis. JBJS Rev. 2017 Dec;5(12):e2
8. Czyzewska, A. et al. Effects of preoperative physiotherapy in hip osteoarthritis patients awaiting total hip replacement. Arch Med Sci. 2014 Oct 27; 10(5): 985–991