Traditional and innovative treatments for osteoarthritis
An interview with Nicholas A. DiNubile, MD
From A Special Report: Osteoarthritis of the Knee
Keeping Aging Adults Active
How important is exercise in the treatment of osteoarthritis?
Exercise is essential in treating people with osteoarthritis. These patients need specific exercises for the joint that is involved: strengthening, range of motion, and flexibility. But even more important, they need general conditioning programs. This includes cardiovascular conditioning or aerobic exercise, as well as strength and flexibility training for the entire body. Exercise is the key not only to living longer, but also to maintaining function as we age and as we get ailments. This is especially important for people with osteoarthritis, who often, because of their disease, lose function and become deconditioned.
The exercise program design can be challenging. Physicians often have to be creative because arthritis patients don't always feel well and they can't do every exercise their physician suggests. The exercise program should be low impact, especially for osteoarthritis of the knee, because high-impact activities can cause progression of arthritis. I recommend water-based exercise programs and stationary bicycles for people with arthritis.
It may be necessary to modify a patient's program. If patients have problems with the exercise program, you don't want them to stop completely and become sedentary. You need to be able to design an exercise program that their arthritic joint will tolerate. It is also important for patients who undergo total joint replacement to get in better shape before and after surgery to improve their recovery and functional outcome.
What is the role of disease management programs for arthritis and osteoarthritis?
Osteoarthritis and arthritis lend themselves to disease management programs. In my role as orthopedic medical director for Aetna US Healthcare, I've seen disease management programs that have been very successful in areas such as asthma and diabetes. And when you think about it, arthritis is similar to those conditions. Arthritis involves many patients, significant costs for treatment, and there is a lot of variation nationally in how people with arthritis are treated. Disease management looks at the whole ailment and focuses on finding people who have arthritis or are at risk of developing arthritis, and looks for comprehensive ways to change their lives. Disease management includes a focus on preventionbeing sure patients get the right care at the right time and in the right settingand it allows physicians to monitor the outcome of treatment.
We are just beginning to see the impact of arthritis on our societyfrom an economic standpoint and from a functional standpoint. Therefore, I think we are going to see a more comprehensive focus on arthritis in the future. And I would challenge health insurance companies, pharmaceutical companies, hospital systems, and physicians who specialize in orthopedics and rheumatology to look at the overall approach to these patients. I think good disease management programs would improve the way people with arthritis are identified and treated.
What has been your experience with viscosupplementation in treating osteoarthritis?
I have seen dramatic improvement in many patients who underwent viscosupplementation. I think the future will help us to identify the patients who are likely to benefit from it and those for whom it might not be appropriate. We need to study this new intervention carefully. It is important not to look at it as a stand-alone treatment for arthritis, but as part of a comprehensive program. I have seen viscosupplementation work in patients who have osteoarthritis of the knee and are therefore inactive and may be overweight. Treatment for these patients is a vicious cycle because they need to be more activethey need to exercise and lose weight. But they can't exercise because of their painful joint. If you can break that cycle of pain and inactivity, even temporarily (because viscosupplementation is not a permanent cure; it's a temporary intervention), you can use that opportunity to get them started on an exercise program when they feel better. When the effects of viscosupplementation start to wear off, the joint is less vulnerable, maybe even less symptomatic because you have allowed those other interventions to take place.
As with any treatment we offer, patients need a clear understanding of what to expect from viscosupplementation. If they think that viscosupplementation will cure their arthritis, they are setting themselves up for disappointment. Patients who understand that viscosupplementation improves, but does not necessarily cure, arthritis and that it is part of a comprehensive program will be more satisfied with the outcome.
What do you predict is on the horizon for treatment of osteoarthritis?
I think the future is very promising. Twenty years ago, during my orthopedic training, I conducted basic science research in the area of articular cartilage repair and transplantation. I have remained familiar with articular cartilage biology and research. In the last decade, we have seen many changes in the approach to osteoarthritis. Now we are not just treating the symptoms, but we are also talking about changing the course of the disease.
Many wonderful things are on the horizon for treatment: the high-technology areas, such as gene therapy, and the use of growth factors and tissue engineering to repair or replace damaged joint surfaces. We are already doing autologous chondrocyte transplantation, and we are able to repair focal joint surface injuries, which means we are able to repair potholes over the joint surface. I believe that technology will be used not only to fix the potholes, but also to repave the road, or repair larger areas of damage-even arthritic areas. Right now we can't do that, but I know we will be able to in the future.
We should never forget the low-technology options. We need to focus more on prevention, not just for arthritis, but throughout healthcare. We spend a trillion dollars on healthcare in this country, and less than 1% of it goes to prevention. We will never tackle the out-of-control spending if we are only treating the disease once it occurs. A focus on prevention will be a wise investment of our healthcare dollars. That is the only way to curb costs because technology to treat disease is only going to get more expensive and more expansive. Therefore, until we start looking at prevention and disease modification, we are going to have the challenge of rising healthcare costs.
Preventive measures are especially important for arthritis. We are seeing more and more arthritic joints for several reasons: We have an aging population with longer life expectancy; a generation of beat-up baby boomers raised on the "no pain, no gain" philosophy; and younger and younger patients with significant predisposing joint injuries. I believe that our newer treatment approaches are already saving many of these joints that otherwise would have been destined for problems.
Nicholas A. DiNubile, MD is clinical assistant professor, department of orthopedic surgery, Hospital of the University of Pennsylvania, Philadelphia, and orthopedic consultant to the Philadelphia 76ers basketball team and the Pennsylvania Ballet. He has been a consultant for Wyeth-Ayerst Laboratories.
Address for correspondence: Nicholas A. DiNubile, MD, Llanerch Medical Center, 510 W Darby Rd, Havertown, PA 19083.
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