Arthritis: Degenerative & Mechanical | BJC Health Connected Care

Knee Osteoarthritis: a not-so-new IDEA 0

By Dr Irwin Lim, Rheumatologist

Knee osteoarthritis is really very common. Particularly, as our population becomes more overweight and sedentary.

Patients will often ask about non-pharmacologic treatment (non-”drug” treatments), looking instead for a “natural” alternative.

Often, the elephant in the room is ignored.

Weight. Too much of it. Excess weight is the most obvious modifiable risk factor in knee osteoarthritis.

At the recent American College of Rheumatology Meeting (ACR 2011) in Chicago, results of the Intensive Diet and Exercise for Arthritis (IDEA) trial were presented. The IDEA trial was designed to test the hypothesis that intensive weight loss, either with or without exercise, would reduce pain and improve function in patients with knee osteoarthritis when compared with those patients who exercised but did not undergo dietary restriction.

454 overweight and obese patients, all older than 55 years, with symptoms related to their knee osteoarthritis were divided into 3 groups:

Intensive Dietary restriction only
Intensive Dietary restriction plus exercise
Exercise only

The goal for the dietary restriction patients was a 10% reduction of baseline body weight. The exercise intervention consisted of low to moderate intensity walking as well as resistance training 3 times a week for 1 hour each time.

After 18 months, mean weight loss for the group on dietary restriction only was 8.9kg. When exercise was combined with dietary restriction, the mean weight loss was 10.6kg.

The exercise only group had much less mean weight loss, only 2kg.

Similarly, pain levels and walking speed (the measure used to assess mobility) improved most in the combination group with dietary restriction and exercise. On these measures, the exercise only group did also show benefit but again, this exercise only group did not do as well when compared to groups with dietary restriction.

The IDEA trial basically shows that weight loss, when combined with low to moderate intensity exercise, can lead to about 50% reductions in pain and to improved function.

The elephant in the room needs to be addressed.

It’s something I expect doctors and allied health professionals have known for some time, but as a group, we tend to be poor in addressing this very important issue. We need to highlight how important weight loss is for our overweight patients with knee osteoarthritis.

In fact, we are doing these patients a disservice if we don’t.

BJC Health’s Connected Care approach emphasises the need for weight loss with knee osteoarthritis. It’s good to see more and more evidence supporting this approach.

Are you addressing the elephant?

Dr Irwin Lim is a rheumatologist and a director of BJC Health.

BJC Health provides a connected care multidisciplinary team philosophy to deliver positive lifestyle outcomes through a holistic approach to those with degenerative & inflammatory arthritis, tendon injury and lifestyle diseases. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on arthritis-related diseases, healthcare in general, and our Connected Care philosophy.

Posted on: 11-20-2011
Posted in: Arthritis: degenerative & mechanical, Connected Care, Diet & Nutrition, Exercise Physiology, Knee & Hip

Treat the whole person, not just the disease! 3

By Irwin Lim, Rheumatologist

At BJC Health, the core philosophy behind our approach is known as Connected Care.

With a multidisciplinary team of physiotherapists, a nutritionist, remedial massage therapists, exercise physiologists, rheumatologists and endocrinologists, we aim to treat the whole person and not just the disease.

Let’s focus on arthritic diseases, which affect 1 in 5 Australians. A patient at BJC Health will be referred within the clinic to the individualised specialist care that they require – it’s about the whole person. I can best explain this by recounting a typical patient story.

Beryl has had increasing knee pain over the last decade, worse on the left side. She now complains of pain and stiffness every time she gets up from a sitting position and with walking. At times, she has pain when she turns in bed.

Beryl was seen by an orthopaedic surgeon who agreed that what she required was total knee replacement surgery. Unfortunately, Beryl has had multiple heart attacks and has poor kidney function. The operation would be very risky for her and it was agreed that she should have non-operative treatment instead.

She was assessed by one of our rheumatologists. The goal was to reduce her pain and improve her general mobility. Beryl wanted desperately to be more active as she has two young grandchildren, and during the consultation, she confided that she wanted to live as long as possible, but only if her quality of life could be improved.

Her rheumatologist told her that she should not take anti-inflammatory medications as she was at increased risk of side effects due to her other medical conditions. A cortisone injection was performed at the left knee. This reduced her pain at that knee by about 50%. As benefits from cortisone injections typically last up to 3 months only, Beryl was also commenced on a knee stability program under the supervision of the physiotherapy team.

At Beryl’s age of 75, strengthening her quadriceps musculature and improving her overall gait and posture can lead to reduced pain, reduced risk of falls, and improved wellbeing. She also consulted the dietitian as weight loss and a healthier diet would also help with the above, as well as helping reduce her risk of further heart attacks and strokes.

BJC Health is pioneering Connected Care and fostering a true partnership between doctor, allied health practitioners and patient. Is this the approach you would like?

Dr Irwin Lim is a rheumatologist and a director of BJC Health.

BJC Health provides a connected care multidisciplinary team philosophy to deliver positive lifestyle outcomes through a holistic approach to those with degenerative & inflammatory arthritis, tendon injury and lifestyle diseases. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy.

Posted on: 03-7-2011
Posted in: Arthritis: degenerative & mechanical, Connected Care

What’s causing that swollen knee? 0

Aspirating a knee joint

by Irwin Lim, Rheumatologist

If you develop a swollen knee, please don’t consider it a normal occurrence.

If there was a clear cause, such as a fall to the knee, or some twisting injury to the knee, it’s likely that the cause is due to some mechanical damage. An easily recognised example would be a football or rugby player sustaining such an injury on the playing field. In that case, its typically serious and when the sportsperson develops an acute swollen knee after a popping or tearing sensation, it’s usually a tear of a major ligament such as the anterior cruciate ligament.

Most of the patients I see do not develop their swollen knees on a sporting arena.

Why is the knee swollen?

In the absence of obvious trauma, we need to work out if the cause of the swelling (effusion is the medical word for increased fluid within the actual joint) is due to degenerative/mechanical causes, or to inflammatory causes.

Degenerative/mechanical causes would typically be due to wearing out of the cartilage as in osteoarthritis, or tears in the menisci (think of these as the knee’s shock absorbers) or any combination of ligament, bone, and cartilage degeneration.

Inflammatory causes include crystal arthritis such as gout, septic arthritis due to various infections, and diseases of the immune system such as rheumatoid arthritis.

The story the patient provides and the clinical examination of the knee will typically give clues as to the cause.

Often investigations are needed. These may include a number of radiological investigations, sometimes including an MRI of the knee. If an inflammatory arthritis is suspected, blood tests are often useful.

One of the most neglected investigations, because it is time-consuming and because of a general lack of technical skill in performing it, is an aspiration of the swelling/effusion. By this, I mean, that a needle is guided into the knee joint to obtain a sample of the joint fluid. If there is a swelling/effusion obviously present, this is a simple procedure for rheumatologists.

This joint fluid, being precious and useful, can then be sent for further analysis. Infection can be excluded. Crystal arthritis can be diagnosed on microscopic examination. The constitution of cells within the fluid will allow us to also differentiate between degenerative/mechanical and inflammatory causes.

Once a clear diagnosis is made, treatment can be planned.

Don’t ignore that swollen knee.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients. We call this model of care, Connected Care. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy.

Posted on: 01-13-2011
Posted in: Arthritis: degenerative & mechanical, Arthritis: inflammatory, Knee & Hip