Rehab Dialogue Arthritis: a pain in the joints and the health-care system
By Lauren Beaupre, PhD and Allyson Jones, PhD
Pursuing your best Faculty of Rehabilitation Medicine | Page 5
34%
of Albertans have arthritis
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70%
of Albertans over the age of 70 have symptoms of osteoarthritis, the most common type of arthritis
Physical therapists can help provide direction and coordination for the conservative management of arthritis, improving function and reducing pain for the patient.
50%
of arthritis patients seen by orthopedic surgeons on their first visit are not considered to be candidates for hip and knee replacement surgery. Physical therapists can be part of the Assessment team, a group of health professionals who determine whether or not a patient should be referred on to a surgeon for hip or knee replacement surgery.
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Arthritis results in the leading number of health care visits, medication use and disability, and is among the most prevalent chronic conditions in Canada. In fact, bone and joint health conditions are leading global causes of morbidity and disability, costing billions in health care expenditure and lost earnings. Approximately 34 per cent of Albertans have arthritis. This number increases with age; there is evidence of osteoarthritis, the most common type of arthritis, in 70 per cent of people over the age of 70. Arthritis is truly ‘a serious chronic disease’ in Alberta and Canada due to its impact on quality of life, mobility and the huge demand it places on heath care resources. End stage arthritis results in unbearable unremitting pain and loss of ability to perform regular daily activities including walking. The ramifications are felt at personal and societal levels and include loss of independence, social isolation, depression, and premature retirement or loss of employment. In keeping with Alberta Health Service’s Quality Matrix for access, safety, effectiveness, efficiency, acceptability and appropriateness, a clinical pathway known as the “Alberta Bone and Joint Network’s Hip and Knee Care Continuum” has recently been approved for adoption across the province. People experiencing pain from arthritis start their journey of care with their primary care physician. When pain and difficulty doing activities related to the arthritis become too great after a period of treatment, the primary care physician will refer the patient to “Assessment,” where an orthopedic surgeon will consider them for joint replacement. Those who are not yet ready or may not need surgery may require physical therapy, medications changes, lifestyle and diet changes and more.
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Strong evidence including recommendations from the Osteoarthritis Research Society International (OARSI) advocate physical and exercise therapy as one of the most effective non-operative interventions for arthritis. Physical therapists are trained specifically in the area of exercise prescription for
improving function and reducing pain for people with arthritis. In several other Canadian provinces, physical therapists have taken a central role in the Assessment process. In Alberta their role in the Assessment stage is still evolving.
Alberta Bone & Joint Network Hip & Knee Care Continuum
Conservative Management (Education & Medical or Surgical Optimization)
NO YES
Patient
Primary Care Physician
Assessment
Specialist (Orthopedic Surgeon)
Health Care Infrastructure
Feedback
Monitoring & Continuous Improvement
Research (Alberta Bone & Joint Health Institute)
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Positive Patient & System Outcomes
What rehabilitation can do
Navigating the care pathway
Currently, physical therapists are involved in the pre- and post-operative management of patients with joint replacement and they can also play an integral role in providing conservative management when surgery is not indicated. They can assist patients as they navigate the health system and receive either conservative or surgical management. Physical therapists’ multidisciplinary skills can help guide patients to the most effective care. They can also provide “prehabilitation” to prepare patients for surgery.
avoid stairs because the pain in his knees was often unbearable. He has likened his pain to “rubbing two sticks together, bone on bone, where the knees felt like they were burning.” After 10 years of conservative management (drug, physical and exercise therapy), he received total knee replacement surgery.
To provide efficient and effective care, more attention needs to be directed to providing an interdisciplinary approach to managing arthritis. The treatment stages for arthritis require contributions from various healthcare professionals. Conservative management of patients with arthritis is multi-faceted and their care may involve several health-care professionals including physical therapists, occupational therapists, family physicians, dieticians, nurses and more. Many orthopedic surgeons and primary care physicians say we need to get away from the belief that improving the service “is only about doing more surgery.”
In response to the long wait times patients experience to consult with orthopedic surgeons for joint replacement surgery, some centres in Ontario employ specialist physical therapists to assist with “triaging” patients to help streamline appropriate care. Physical therapists can be part of the Assessment team that evaluates care options to avoid unnecessary wait times to consult for surgery. They can make an initial assessment to determine if the patient should consider conservative management, prehabilitation or be recommended for surgery, directing patients to the appropriate health service providers. The role of physical therapists assessing patients with arthritis can assist Rehabilitation professionals such as physical and the general practitioner by providing effective occupational therapists are trained to assess and treatment when a patient is told that surgery is not treat patients with arthritis. Physical therapists yet a recommended option. provide treatment to maintain and restore optimal movement and function while reducing pain. They work in a strong interdisciplinary culture and are able to connect and refer patients to other health An Albertan with osteoarthritis moved from care professionals when necessary. a two-story home to a bungalow in order to
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Conservative management and “prehabilitation”
Future directions
Given the growing demand for arthritis treatment, the involvement of physical therapists in the Within the Alberta Bone and Joint Network’s care Assessment phase, to provide care and help patients pathway, patients have well-defined points of contact navigate the care pathway, will ensure efficient to start their journey for hip and knee replacement and excellent patient outcomes. Creating a more surgery. Yet no clear pathway exists for patients flexible approach to direct patients who are not surgical candidates through the optimal treatment and find themselves “swirling” Given the growing demand pathway will provide effective, between options of care, methods appropriate care for patients and for arthritis treatment, and levels of funding, and the ensure that clinical resources are the involvement of different professionals offering used wisely. Physical therapists services. The Network is looking physical therapists in can also help the Network for solutions. As musculoskeletal establish a care pathway within the Assessment phase, specialists, physical therapists the Conservative Management can provide direction and to provide care and help phase, working closely with coordination for these patients by primary care networks to allow patients navigate the working closely with and within patients with arthritis to enjoy primary care networks. Primary care pathway, will ensure better quality of life. When care physicians need physical end-stage arthritis is reached, efficient and excellent therapists to coordinate and a prehabilitation program may connect with them. patient outcomes. help patients prepare for knee or hip replacements and help them Another facet of the Conservative recover more quickly. Physical therapists and other Management stage is “prehabilitation,” preparing allied health professionals can work with the patient for surgery. Some patients who are deemed surgical to improve their preoperative physical condition, candidates may need a specific preparation program, preparing them for excellent clinical outcomes. provided by experienced physical therapists, to optimize their recovery and surgery outcomes. The province’s aging population is growing and Successful recovery after joint replacement is, in part, demand for hip and knee replacements continues dependent upon the patient’s level of pre-operative to rise. Rehabilitation professionals are keen health and function—the patient’s condition before to continue to team up with other health care surgery. One of the authors of this dialogue, Allyson professionals to enhance the care continuum. Jones, has shown that patients who were in what They are ready and willing to play a greater role in was considered poor physical condition before developing the best outcomes for patients, whether undergoing hip or knee replacement didn’t fare as they need surgery or not. well as other patients. They were less mobile and experienced more pain at six months after surgery. A prehabilitation program to prepare patients is intended to help them gain more benefit from hip or knee surgery. Along with researchers from Toronto and Houston, the authors are currently studying the effect of preoperative rehabilitation for patients who are waiting for knee replacement and have serious difficulties with pain and mobility. The protocol calls for an eight week pre-surgery program involving a physical therapist visiting the individual in their home to review pain management, discuss expectations after surgery, introduce basic stretching and strengthening exercises, and instruct on the use of a cane or walker. The ultimate aim is to prepare the patient so that optimal recovery can be achieved after knee replacement surgery. An additional benefit of prehabilitation is that the therapist-patient relationship has been established already for the intensive therapy sessions needed post surgery.
Physical therapists can also help the Network establish a care pathway within the Conservative Management phase...
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Lauren Beaupre, PhD, is an Associate Professor in the Faculty of Rehabilitation Medicine’s Department of Physical Therapy at the University of Alberta. She is also cross appointed with the Department of Surgery (Division of Orthopaedic Surgery). She has a PhD in Epidemiology and an MSc and BSc in Physical Therapy from the U of A. Prior to joining the Department of Physical Therapy, Beaupre worked as the Orthopaedic Research Director in Capital Health performing clinical outcomes research. Beaupre’s current research projects include investigation of recovery following hip fracture in continuing care patients, osteoporosis management in hip fracture patients, outcomes following total hip and knee arthroplasties, recovery following compound fractures of long bones and outcomes following shoulder surgery. Funding for current research comes from the Canadian Institutes of Health Research (CIHR), Alberta Heritage Foundation for Medical Research (AHFMR), local hospital foundations and industry sponsors.
Allyson Jones, PhD, is an Associate Professor in the Faculty of Rehabilitation Medicine’s Department of Physical Therapy at the University of Alberta. She is also a Fellow with the Institute of Health Economics. She has a PhD in Epidemiology and a MSc in Physical Therapy from the U of A, a BA in Administrative Studies from the University of Winnipeg and a BSc in Physical Therapy from the University of Saskatchewan. Jones completed a CIHR/AHFMR Postdoctoral Fellowship in health-related quality of life. She received a New Investigator Award from the American Geriatrics Society for her postdoctoral work. Jones is a CIHR New Investigator (2006-2011) and AHFMR Population Health Investigator (2007-2014). Jones looks at functional, health-related quality of life and health services outcomes to determine how we can maximize successful outcomes with total joint arthroplasty, spinal stenosis and hip fracture. Her current projects include: patient-related outcomes, determinants of total hip and knee arthroplasties; prognostic factors and outcomes of degenerative lumbar spinal stenosis; and factors affecting functional recovery and health related quality of life of hip fracture. Funding for current research comes from AHFMR, CIHR and the U of A. Jones continues to practice clinically as a physical therapist.
Rehab Dialogue is a series of interactive articles published by the University of Alberta Faculty of Rehabilitation Medicine. We invite government, health-care professionals and the community to engage in discussion on various health-care topics where rehabilitation could or should play a more important or greater role, improving function, reducing pain, maximizing potential and quality of life—and sharing the vision for a healthy Alberta.
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