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Introduction   

Osteoarthritis (OA) is a form of arthritis and affects the quality of life for those who suffer from it. Osteoarthritis (OA) occurs in two forms: primary OA, which develops without a clear cause, and secondary OA, which results from an underlying condition or injury [1]. The clinical presentation of OA can range from being an incidental finding with no symptoms to causing severe and permanent disability. 

In the case of knee osteoarthritis (KOA), the most common type of arthritis when compared to any other joint, the condition can disrupt the underlying knee joint biomechanics, worsening the disease [2]. The increased load on the knee joint exacerbates gait and posture issues, making mobility more challenging. This additional strain accelerates KOA progression, and the use of analgesics for pain relief can contribute to further joint overload and the chronicity of the disease. Effective management of knee osteoarthritis (KOA) emphasizes reducing joint load to slow disease progression [3]. A 2001 report by the World Health Organization (WHO) reveals that knee osteoarthritis (OA) affects 365 million people worldwide, accounting for 73% of the 528 million individuals diagnosed with osteoarthritis [4]. In the United States, knee OA impacts at least 19% of adults aged 45 and older [5]. 

Non-pharmacological interventional strategies are essential in the comprehensive management of knee osteoarthritis (KOA), as they are for any joint affected by osteoarthritis [6]. These strategies can reduce pain, improve joint function, and slow disease progression [6]. Key interventions include lifestyle modifications such as weight management and exercise, physical therapies, and the use of assistive devices. By emphasizing these approaches, individuals with KOA can manage their symptoms and enhance their quality of life without depending solely on medication. 

Non-pharmacological interventions (NPIs) have proven effective in managing mild to moderate osteoarthritis [6]. These include patient education, lifestyle changes, weight reduction, regular exercise, physiotherapy, and the use of orthopedic devices like canes, insoles, and braces [6]. There is convincing evidence supporting the efficacy of these load-reduction strategies, which also encompass the use of variable-stiffness shoes, knee bracing, and gait modification [7][8]. Acupuncture is under investigation as a potential therapy for KOA, highlighting the continuous search for effective management strategies [9].  

As a chronic condition with no cure, OA affects the physical health and has significant emotional impacts. Individuals with OA are at a higher risk of developing anxiety and depression, which can interfere with their ability to engage in daily activities, enjoy hobbies, spend meaningful time with loved ones, and participate in self-management practices like exercise [10]. Pre-existing mental health conditions can further diminish a patient’s motivation or ability to engage in self-care. Therefore, a comprehensive, individualized treatment plan for OA should address not only physical symptoms but also social support, sleep, coping strategies, and mental health [11]. 

Epidemiology 

Osteoarthritis (OA) affects 3.3% to 3.6% of the global population, making it a significant public health concern [12]. It is a leading cause of disability, impacting around 43 million people with moderate to severe disability, and ranks as the 11th most debilitating disease worldwide. In the United States, 80% of people over 65 show radiographic signs of osteoarthritis (OA) [12]. However, only 60% of them report symptoms, as radiographic OA occurs at least twice as often as symptomatic OA [12]. This highlights that radiographic findings alone do not confirm OA as the source of joint pain [12].  

The direct costs associated with osteoarthritis (OA) represent 1–2.5% of the Gross National Product in countries with established market economies, including the US, UK, Canada, and Australia [13]. In 2013, OA was the second most expensive medical condition treated in US hospitals, contributing to 4.3% ($18.4 billion) of the total hospitalization costs, which amounted to $415 billion [13]. The estimated direct medical costs of OA in the U.S. alone reach almost $72 billion, based on average cost data from 2008–2011 [13]. 

Pathophysiology  

Osteoarthritis (OA) is a condition that affects the entire joint, involving all its tissues. The development of osteoarthritis (OA) occurs within a complex interplay of risk factors, along with mechanical stress and abnormal joint mechanics [14]. This interplay triggers the release of pro-inflammatory markers and proteases, which contribute to the progressive destruction of the joint [14]. 

The initial changes in osteoarthritis (OA) manifest in the articular cartilage, where surface fibrillation, irregularities, and localized erosions begin to develop [12]. These erosions can extend down to the bone and expand to involve more of the joint surface. On a microscopic level, after cartilage injury, the collagen matrix is damaged, causing chondrocytes to proliferate and form clusters [12]. As the disease progresses, hypertrophic chondrocytes undergo a phenotypic change, leading to the formation of cartilage outgrowths that ossify into osteophytes [12][15].  

As the collagen matrix sustains further damage, chondrocytes undergo apoptosis [12]. The improper mineralization of collagen results in subchondral bone thickening, and in advanced stages of the disease, bone cysts may develop [15] [16]. Even rarer, bony erosions appear in erosive OA [16]. There is also some degree of synovial inflammation and hypertrophy, although this is not the inciting factor as is the case with inflammatory arthritis [12]. Soft-tissue structures, including ligaments, the joint capsule, and menisci, experience direct impact. In end-stage osteoarthritis, calcium phosphate and calcium pyrophosphate dihydrate crystals appear [17]. While their exact function remains uncertain, these crystals play a part in triggering synovial inflammation. 

Treatment 

The primary goals in treating osteoarthritis (OA) are to minimize pain and prevent functional loss [12]. Effective management of OA involves a combination of non-pharmacologic and pharmacologic therapies. Manage mild symptoms with non-pharmacologic approaches alone, while advanced disease necessitates a combination of both non-pharmacologic and pharmacologic methods.  

Key components of non-pharmacologic therapy include: 

1. Avoidance of Aggravating Activities: Patients should avoid activities that exacerbate pain or place excessive stress on the affected joint.
2. Exercise: Strengthen joints and improve function by engaging in exercises that combine aerobic and resistance training. These programs can reduce pain and enhance physical function, making them essential recommendations for healthcare providers.
3. Weight Loss: For individuals who are overweight or obese, weight loss is a critical intervention. Every pound of weight loss can decrease the load on the knee by three to six times, reducing joint stress [12].
4. Occupational Therapy and Assistive Devices: Occupational therapy can help in offloading joints through the use of braces, splints, canes, or crutches. Engage in aerobic and resistance exercises to strengthen joints and improve function. These programs reduce pain and enhance physical function, making them crucial recommendations for healthcare providers
5. Correction of Joint Malalignment: Mechanical interventions such as realignment knee braces or orthotics may be necessary to correct joint malalignment and improve function. 

Non-pharmacologic therapies form the foundation of OA management and serve as the primary treatment approach [18]. Implement these therapies from the outset and continue alongside disease progression. These interventions include: 

• Patient Education 

• Physical Activity 

• Weight Loss 

• Assistive Devices, Braces, and Taping 

• Psychosocial Treatments 

• Complementary & Integrative Health Therapies 

• Referral to Other Specialties 

Patient Education 

Effective management of osteoarthritis (OA) hinges on comprehensive patient education, as successful treatment relies on the patient’s active participation. Correcting common misconceptions is essential for improving symptom management and enhancing a client’s quality of life. These misconceptions include the beliefs that osteoarthritis (OA) is a consequence of aging, that no interventions can help, that severe disability is inevitable, and that exercise exacerbates pain [19]. 

Empowering patients to take control of the daily challenges posed by OA is a key aspect of treatment. By linking patients with evidence-based self-management education (SME) programs and community resources, healthcare providers can equip them with the knowledge and confidence needed to manage their condition. Active involvement reduces both immediate and long-term health impacts, leading to the best quality of life for individuals living with OA [20]. 

Physical Activity and Weight Management in OA Management 

Physical activity and weight management are foundational therapies for managing osteoarthritis (OA). Engaging in regular physical activity reduces pain, alleviates stiffness, and enhances physical function in individuals with OA [21]. A meta-analysis by Wallis et al. found that patients with severe knee OA awaiting joint arthroplasty experienced reduced pain after participating in pre-operative exercise programs [22]. 

Recommended Physical Activity Guidelines 

National guidelines suggest 150 minutes of moderate-intensity physical activity per week, along with two strength training sessions [23]. Moderate-intensity activity involves engaging in exercises like brisk walking, slow biking, general gardening, or ballroom dancing. Dedicating just 45 minutes a week to moderate-to-vigorous physical activity can improve or maintain function in adults with lower extremity osteoarthritis [23]. 

Assessing Physical Activity 

To ensure patients are engaging in adequate physical activity, clinicians can incorporate “Physical Activity as a Vital Sign” into routine assessments [24]. This approach, similar to the regular measurement of blood pressure, helps gauge how often a patient is active and can guide discussions about setting realistic physical activity goals. You can assess clients’ current activity levels and their readiness to increase physical activity using tools like SNAP, PAVS, and EVS [25]. 

Personalized Exercise Plans 

Tailor physical activity to align with each patient’s abilities and limitations. For patients hesitant about “exercise,” encouraging them to simply “move more” can be a less daunting goal. Simple suggestions include: 

• Walking around the house while on the phone 

• Marching in place during commercials 

• Parking farther from the store entrance 

• Engaging in yard work or household chores 

Addressing Concerns About Exercise 

Patients may fear that physical activity will worsen their pain or joint damage. Clinicians should emphasize that exercise can reduce pain and protect joints, and that reducing inactivity is also beneficial [26]. It is important to reassure patients that engaging in regular movement is safe and can lead to better outcomes. 

Types of Exercise to Consider: 

• Low-Impact Land-Based Aerobic Exercise: Engage in low-impact activities like walking and biking to reduce stress on weight-bearing joints, including the knees, hips, and spine. These activities protect joints but also promote and support cardiovascular and emotional health.  

• Low-Impact Aquatic Aerobic Exercise: Aquatic exercises, such as water aerobics or pool therapy, provide muscle-strengthening benefits while reducing joint loading. Land-based and aquatic exercises improve arthritis symptoms and enhance overall quality of life. A meta-analysis revealed participants in aquatic exercise programs exhibit higher adherence and satisfaction rates compared to those in land-based programs [27]. 

• Strengthening Exercises: Strength training benefits clients with knee and hip osteoarthritis (OA). Weakness in the quadriceps is a risk factor for knee OA, and loss of leg strength is associated with increased pain and disability [28]. Resistance exercises, using weights or bands, can improve pain and function in these patients. Whole-body resistance training also enhances self-efficacy, self-esteem, and reduces anxiety and depression. 

• Flexibility and Range of Motion Exercises: Flexibility exercises promote cartilage health, safeguard joints, and enhance comfort in daily activities. Patients should focus on low-impact, controlled movements that avoid increasing pain.  

• Tai Chi & Yoga: These practices enhance flexibility, balance, and mental health. Explore more details in the Complementary & Integrative Health section. 

S.M.A.R.T. Tips for Safe Exercise 

To help patients safely increase their physical activity, the Center for Disease Control and Prevention’s (CDC) S.M.A.R.T. tips offer practical advice [29]: 

• Start low, go slow. 

• Modify activity when arthritis symptoms increase but try to stay active. 

• Engage in joint-friendly activities. 

• Recognize safe places and methods to be active. 

• Consult a health professional or certified exercise specialist. 

Lifestyle Management Programs for Arthritis 

Several evidence-based physical activity programs target individuals with arthritis, providing safe methods to increase physical activity.  

Examples include: 

• Active Living Every Day: A classroom-based program that meets weekly for 12-20 weeks, focusing on increasing physical activity and improving overall health. 

• Fit and Strong: A group-based program for older adults, combining exercise with arthritis management education in 90-minute sessions held three times a week for eight weeks. 

• Walk With Ease (WWE): A six-week program from the Arthritis Foundation offering practical advice on walking safely, along with strategies for maintaining progress. 

• Enhance Fitness: An informal, group-based program suitable for all fitness held in gyms or community centers, offering benefits like increased strength, flexibility, and mood improvement. 

Weight Loss and Osteoarthritis Management 

Excess weight increases the biomechanical load on weight-bearing joints, compromising joint integrity and intensifying pain. Research indicates that a 10-pound weight loss in an overweight individual can reduce the risk of developing knee osteoarthritis (OA) by 50% and decrease knee joint loading by 40 pounds [30]. 

In the IDEA trial (Intensive Diet and Exercise for Arthritis), participants with knee OA who were overweight and achieved a modest weight loss of 10% of their body weight through diet and exercise experienced a 50% reduction in pain scores [31]. This highlights the profound impact that even modest weight loss can have on reducing OA symptoms. 

Importance of Weight Loss Counseling 

Weight loss counseling plays a crucial role in achieving successful outcomes for patients with OA. According to the CDC, overweight or obese adults with arthritis who receive counseling from their healthcare provider are four times more likely to attempt weight loss [30] [32]. Primary care providers can enhance their patients’ success by using strategies like motivational interviewing, directing them to appropriate resources, and educating them on the benefits of even small weight reductions in decreasing joint load and pain. 

For additional resources, the Obesity Action Coalition (OAC) offers a range of materials, including brochures, guides, and fact sheets on obesity and related topics like osteoarthritis [33].  

Practical Tips for Managing Weight 

• Practice Mindful Eating: Focus on the taste and texture of your food and how you feel while eating. Avoid distractions like television or reading to become more aware of your eating habits. 

• Eat a Healthy Snack Before Meals: Consuming a salad or a piece of fruit before a meal or social event can help prevent overeating. 

• Pre-Portion Snacks: Instead of eating directly from the package, portion out snacks to control intake. 

• Control Portions When Eating Out: Request a to-go container at the beginning of the meal and wrap up half of your portion before you start eating. 

• Choose Water Over Sugary Beverages: Enhance the appeal of water by adding fruit slices or opting for sparkling water. 

• Stay Full Longer: Replace high-calorie foods with those high in water and fiber, such as beans, whole grains, broths, fruits, and vegetables. 

• Consult a Dietitian: For personalized advice and support, consider seeking guidance from a dietitian. 

Referral to Other Specialties 

The management of osteoarthritis (OA), like many chronic conditions, requires a tailored approach for each patient. An interprofessional strategy, where patients collaborate with a team of healthcare providers, is essential for developing a comprehensive and effective management plan. This team may include specialists such as podiatrists, physical therapists (PT), occupational therapists (OT), orthopedic surgeons, sports medicine experts, mental health professionals, rheumatologists, dietitians/nutritionists, and practitioners of naturopathy or integrative medicine. 

Physical and Occupational Therapy 

Refer the client to physical therapy (PT) or occupational therapy (OT) when identifying functional deficits. These professionals can offer manual therapy, exercise programs, and guidance on improving activity levels, balance, and gait. They are also crucial for teaching the safe and effective use of assistive devices like canes or walkers, and for selecting and fitting appropriate braces. Older adults or those with compromised balance due to arthritis may benefit from community-based fall prevention programs that focus on enhancing agility and strength to reduce the risk of injury.  

Orthopedics 

For patients with more severe knee or hip OA, referral to an orthopedic specialist may be necessary when non-operative interventions are no longer effective. Orthopedic consultation may lead to considerations for surgical options, such as joint replacement (arthroplasty) or intra-articular injections. However, it is important to note that up to 20% of patients who undergo total joint replacement surgery report significant long-term pain despite the surgery [34]. Patients at higher risk for persistent pain after surgery have widespread pain, significant preoperative pain, a high BMI, comorbid conditions, and depressive symptoms [34]. 

Conclusion

Osteoarthritis (OA) is a pervasive and debilitating condition that impacts individuals’ quality of life worldwide [1]. As the most usual form of arthritis, OA requires a comprehensive, multi-faceted approach to management. strategies should incorporate both non-pharmacologic and pharmacologic therapies to address the unique needs of each individual. Effective OA management emphasizes reducing joint load in weight-bearing joints like the knees and hips [6][12]. Combine weight management strategies, engage in regular physical activity, and use assistive devices to achieve this goal.  

Non-pharmacologic interventions, such as patient education, exercise, and lifestyle modifications, form the cornerstone of treatment, helping to slow disease progression and improve patients’ overall quality of life. Addressing mental health and providing psychosocial support are essential because OA often results in anxiety, depression, and social withdrawal [10]. 

Interprofessional collaboration is key to developing a patient-specific management plan, involving specialists from various fields such as orthopedics, physical therapy, dietetics, and mental health. While OA presents significant challenges, a well-rounded, personalized approach that includes patient empowerment, multidisciplinary care, and proactive symptom management can enhance the lives of those affected by this chronic condition through early initiation of non-pharmacological management. 

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