Osteoarthritis

Negative knee OA beliefs drive patients towards surgery


Patients with endstage knee osteoarthritis universally describe their condition as “bone on bone” and are pessimistic about the future, a study shows.

They believe their condition could only deteriorate over time and that surgery or even experimental treatments were their only hope.

According to a qualitative study of 27 patients on a wait list for knee arthroplasty in Melbourne, most patients were also accepting of “wear and tear” as the reason for the inevitability of surgery.

Most described a lack of confidence in their joint – that it might “give way” – and a fear that they might cause it more damage.

Their beliefs regarding the downward trajectory of osteoarthritis appear to reinforce their sense of urgency about a knee replacement.

Many were aware that weight loss might help their knee pain but few engaged in exercise.

“One of the worst parts about it is that if I was more active, I could lose a bit of weight and take weight off [the knee]. But you’re buggered because you can’t do something as simple as walk down the street,” a participant responded.

They felt a mechanical problem largely required a mechanical solution such as surgery or experimental techniques to replace their cartilage.

“Believing that one’s knee joint was bone on bone, caused by wear and tear that was exacerbated by increased loading through the knee and would only get worse over time, motivated participants to minimize loading through the knee and seek treatments they perceived would replace worn cartilage,” the study said.

Co-author Dr Samantha Bunzil, a physiotherapist and post-doctoral researcher at the University of Melbourne and St Vincent’s Hospital, told the limbic that simplistic terminology and imagery was preventing behaviour change that could help patients.

“So there is some difficulty with that term ‘bone on bone’ and we know it is coming from GPs, from physios as well in interpreting the results of scans, and from surgeons.”

“Collectively these three key care providers need to change that wording.”

She said patients perceived a direct link between such descriptions and the intensity of their pain. Instead, clinicians should be explaining to patients that pain was more than just what was happening in their knee.

“We know there are lots of things that can influence knee pain like structure, strength, activity levels, body weight and even mood. These things can all influence pain and the ability to exercise.”

Dr Bunzil said clinicians should be finding ways to address all modifiable factors such as strength, body weight and mood.

“Behaviour change is really tricky. Losing weight and doing more exercise requires more than just telling people they need to do it before surgery especially when they are in pain. People need strategies to be able to control their pain while they are exercising.”

She said there was also a widespread myth that all people with osteoarthritis would only get worse with time.

“The research shows us that people can be stable over time and certainly with exercise that can really change the trajectory.”

“There are some nice studies that have been done of people on the waiting list for surgery who have been randomised to an exercise intervention and have actually taken themselves off the list at the end of the intervention because they feel that their pain was under control enough that they don’t need surgery.”

“We see that as having changed their trajectory. They see themselves as having improved. In some cases that delays surgery quite significantly,” she said.

However, she admitted that short consultations were not conducive to enabling behaviour change.

“It’s really hard to tap into all the factors influencing behaviour in a 5-10 minute session.”

And there were structural barriers such as the fact GPs were much more likely to refer patients to an orthopaedic surgeon than they were to a physiotherapist for an exercise intervention, she added.

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