Faculty of Rehabilitation Medicine | Page 5

Pursuing your best

Arthritis: a pain in the joints and the health-care system

Rehab Dialogue

By Lauren Beaupre, PhD and Allyson Jones, PhD

Join the conversation at rehabdialogue.blogspot.com

Faculty of Rehabilitation Medicine | Page 5Faculty of Rehabilitation Medicine | Rehab Dialogue 2010 Issue 1 | Page 2

34%of Albertans have arthritis

Faculty of Rehabilitation Medicine | Rehab Dialogue 2010 Issue 1 | Page 3

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.

of Albertans over the age of 70 have symptoms of osteoarthritis, the most common type of arthritis

70%

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.

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.

Faculty of Rehabilitation Medicine | Rehab Dialogue 2010 Issue 1 | Page 4

Patient Primary Care Physician

Assessment

Conservative Management(Education & Medical or Surgical Optimization)

Alberta Bone & Joint NetworkHip & Knee Care Continuum

NO

YES

Specialist(Orthopedic Surgeon)

Research(Alberta Bone & Joint Health Institute)

Monitoring & Continuous

Improvement

Feedback

Health CareInfrastructure

Positive Patient

& System Outcomes

Faculty of Rehabilitation Medicine | Rehab Dialogue 2010 Issue 1 | Page 5

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.

Faculty of Rehabilitation Medicine | Rehab Dialogue 2010 Issue 1 | Page 6

What rehabilitation can doTo 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 health-care 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.”

Rehabilitation professionals such as physical and occupational therapists are trained to assess and treat patients with arthritis. Physical therapists 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 care professionals when necessary.

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.

Navigating the care pathwayIn 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 the general practitioner by providing effective treatment when a patient is told that surgery is not yet a recommended option.

An Albertan with osteoarthritis moved from a two-story home to a bungalow in order to 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.

Faculty of Rehabilitation Medicine | Rehab Dialogue 2010 Issue 1 | Page 7

Conservative management and “prehabilitation”Within the Alberta Bone and Joint Network’s care pathway, patients have well-defined points of contact to start their journey for hip and knee replacement surgery. Yet no clear pathway exists for patients who are not surgical candidates and find themselves “swirling” between options of care, methods and levels of funding, and the different professionals offering services. The Network is looking for solutions. As musculoskeletal specialists, physical therapists can provide direction and coordination for these patients by working closely with and within primary care networks. Primary care physicians need physical therapists to coordinate and connect with them.

Another facet of the Conservative Management stage is “prehabilitation,” preparing for surgery. Some patients who are deemed surgical candidates may need a specific preparation program, provided by experienced physical therapists, to optimize their recovery and surgery outcomes. Successful recovery after joint replacement is, in part, dependent upon the patient’s level of pre-operative health and function—the patient’s condition before surgery. One of the authors of this dialogue, Allyson Jones, has shown that patients who were in what was considered poor physical condition before undergoing hip or knee replacement didn’t fare as 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 pre-operative 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.

Future directionsGiven the growing demand for arthritis treatment, the involvement of physical therapists in the Assessment phase, to provide care and help patients navigate the care pathway, will ensure efficient and excellent patient outcomes. Creating a more

flexible approach to direct patients through the optimal treatment pathway will provide effective, appropriate care for patients and ensure that clinical resources are used wisely. Physical therapists can also help the Network establish a care pathway within the Conservative Management phase, working closely with primary care networks to allow patients with arthritis to enjoy better quality of life. When end-stage arthritis is reached, a prehabilitation program may help patients prepare for knee or hip replacements and help them

recover more quickly. Physical therapists and other allied health professionals can work with the patient to improve their preoperative physical condition, preparing them for excellent clinical outcomes.

The province’s aging population is growing and demand for hip and knee replacements continues to rise. Rehabilitation professionals are keen to continue to team up with other health care professionals to enhance the care continuum. They are ready and willing to play a greater role in developing the best outcomes for patients, whether they need surgery or not.

Given the growing demand for arthritis treatment,

the involvement of physical therapists in

the Assessment phase, to provide care and help

patients navigate the care pathway, will ensure

efficient and excellent patient outcomes.

Physical therapists can also help the Network establish a care pathway within the Conservative Management phase...

Faculty of Rehabilitation Medicine | Page 5

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.

Join the conversation at rehabdialogue.blogspot.com

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.