4.3: Osteoarthritis

Massage Therapy for People with Osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis, affecting an estimated 302 million people worldwide, this is a condition characterized by cartilage degradation and bone remodeling which in some cases can lead to pain, stiffness, swelling, and loss of normal joint function (Kolasinski et al., 2020).

Pathophysiology

Osteoarthritis is a common finding in the general population, and most commonly will affect knees, hips, hands, and the spine. In addition to tissue degeneration this condition involves sensitization of the nervous system, which may result in patients with osteoarthritis perceiving relatively low-level stimuli as being overtly painful (Hunter & Bierma-Zeinstra, 2019).

Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Outcome Measurements

Clinicians could incorporate one or more of the following validated outcome measurements when assessing and monitoring patient progress:

• Patient Global Impression Change
• Pain Self Efficacy Scale
• Self-Rated Recovery Question
• Patient Specific Functional Scale
• Brief Pain Inventory (BPI)
• Numeric Pain Rating Scale (NPRS)
• Visual Analogue Scale (VAS)
• McGill Pain Questionnaire (MPQ) or The Revised Short McGill Pain Questionnaire Version-2 (SF-MPQ-2)
• Multidimensional Pain Inventory
• Short Musculoskeletal Function Assessment (SMFA)
• Knee Injury and Osteoarthritis Outcome Score (KOOS)
• Hip Disability and Osteoarthritis Outcome Score (HOOS)
• Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
• Six Minute Walk Test

Treatment

Skills-based capability framework for health professionals providing care for people with osteoarthritis

There are a number of rehabilitation strategies for osteoarthritis based on patient-specific assessment findings including, but not limited to self-management and education, exercise, and manual therapy. A skills-based capability framework helps to facilitate individualized treatment decisions regarding the management of osteoarthritis (Hinman et al., 2020), this includes but is not limited to:

1. communication
2. person-centered care;
3. history-taking;
4. physical assessment;
5. investigations and diagnosis;
6. interventions and care planning;
7. prevention and lifestyle interventions;
8. self-management and behavior change;
9. rehabilitative interventions;
10. pharmacotherapy;
11. surgical interventions;
12. referrals and collaborative working;
13. evidence-based practice and service development

Education

Provide reassurance and facilitate an evidence based understanding of treatment options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms. Reassess the patient’s status at each visit for new or worsening symptoms, or satisfactory recovery.

Manual Therapy

Clinical practice guidelines and randomized controlled trials recommend the use of manual therapy as part of a multi-modal approach for patients with osteoarthritis related pain (Busse et al., 2017; Bowden et al., 2020; Kolasinski et al., 2020; Skelly et al., 2020). Two recent randomized clinical trials have highlighted the effect of conservative treatment options for patients suffering from osteoarthritis related knee pain. In one randomized clinical trial published in the Journal of General Internal Medicine massage therapy was shown to improve function in patients who suffer from osteoarthritis related knee pain (Perlman et al., 2019). In addition, a randomized trial published in The New England journal of medicine demonstrated the benefits of a conservative multimodal approach (manual therapy + exercise) for patients with symptomatic osteoarthritis of the knee (Deyle et al., 2020).

It is not suggested that massage therapy alone can control symptoms but can be utilized to help relieve pain & reduce anxiety when integrated with standard care. Ascribing a patient’s pain solely to a tissue-driven pain problem is often an oversimplification of a complex process. This insight provides us with an opportunity to re-frame our clinical models. Massage therapy is a form of peripheral somatosensory stimulation that can modulate the activity of neuro-immune (peripheral, cortical, subcortical) processes correlated with the experience of pain (Bialosky et al., 2018). By activating ascending and descending inhibitory systems, massage therapy may be able to mitigate the transition, amplification and development of chronic pain.

Self-Management Strategies

Exercise programs for muscle strengthening, joint mobility, proprioception and aerobic exercises is a core treatment for people with osteoarthritis (Daste et al., 2021). People with osteoarthritis should be encouraged to engage in physical activity, irrespective of duration. There is good evidence that even modest volumes of exercise will benefit people with arthritis-related pain (Kraus et al., 2019).

Prognosis

Clinical practice guidelines for osteoarthritis are moving towards an interdisciplinary approach with an emphasis on self-management, physical and psychological therapies, and less emphasis on pharmacological and surgical treatments (Bannuru et al., 2019; Kolasinski et al., 2020). Pharmacological treatments options such as opioid analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) have small effects on osteoarthritis related pain and are associated with adverse effects (Chou et al., 2020; Fuggle et al., 2019; Gregori et al., 2018; Machado et al., 2015; Osani et al., 2020; Osani et al., 2020; Zeng et al., 2019. Research also has demonstrated that corticosteroid injections can harm the joint resulting in cartilage loss, accelerated progression of osteoarthritis, and increase the risk of requiring arthroplasty (Kompel et al., 2019; Wijn et al., 2020).

Embracing an interprofessional strategy for pain treatment can include the use of conservative pain management strategies including but not limited to low-impact exercise, acupuncture, hydrotherapy, manual therapy, and psychological therapies as part of a multidimensional treatment approach for patients suffering from osteoarthritis related pain (Bannuru et al., 2019; Busse et al., 2017; Kolasinski et al., 2020; Lin et al., 2020; Skelly et al., 2020).

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for osteoarthritis based on patient-specific assessment findings including, but not limited to:

• Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
• Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
• Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
• Hydrotherapy (hot & cold)
• Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

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