Physiotherapy for Large Joint Arthritis Miss Bridget Dean

In this podcast, Bridget Dean, the lead physiotherapist at Macquarie Health Physiotherapy, offers an in-depth analysis of osteoarthritis (OA), a prevalent degenerative joint disease that impacts millions worldwide. With a strong background in physiotherapy and education, Bridget emphasizes the essential role of physiotherapists and general practitioners in early detection, patient education, and comprehensive management of OA. She begins by defining osteoarthritis, explaining that it primarily involves the breakdown of cartilage due to mechanical stress and inflammation, which ultimately affects the entire joint structure.

Recognizing that OA significantly diminishes patients' quality of life, Bridget highlights the condition's common symptoms of chronic pain, stiffness, and reduced mobility. These symptoms not only impose physical limitations but also contribute to psychological issues, such as anxiety and depression, creating a cycle that exacerbates the decline in patients’ overall well-being. She stresses the importance of a multifaceted approach to treatment, which includes lifestyle modifications and psychological support, in order to provide holistic care for those affected.

Bridget outlines a structured physiotherapy approach to managing OA that revolves around five key principles: controlling symptoms, slowing disease progression, optimizing function, enhancing quality of life, and ensuring effective use of healthcare resources. To meet these goals, she presents five critical components of treatment, which include patient education and self-management, exercise regimes for strength and cardiovascular health, weight management, physiotherapy aids, and psychological support. The incorporation of these strategies helps empower patients to take control of their condition and improve their quality of life.

She also discusses evidence-based educational programs, such as the GLAAD (Good Life with Osteoarthritis in Denmark) program and the PEAK (Physiotherapy Exercise and Physical Activity for Knee Arthritis) program. Both initiatives are structured and standardize approaches to managing OA, providing initial assessments, education, and supervised sessions that equip patients with the tools they need to manage their condition effectively. However, Bridget cautions that the evidence remains inconsistent for prehabilitation programs, which necessitates standardized guidelines for optimal intervention and outcome measures.

Bridget emphasizes the significance of effective preoperative physiotherapy, noting that its primary objective should be enhancing cardiovascular fitness and facilitating weight loss in preparation for surgery. She discusses how structured education empowers patients by clarifying expected surgical outcomes and encouraging adherence to rehabilitation protocols. The key focus should be on mobility exercises that promote early healing, the appropriate use of walking aids, gait training to restore natural movement, and promoting independence in daily activities.

Crucially, she highlights the importance of continuous care throughout the recovery journey, whether it occurs in a hospital or home setting. Research indicates that home-based rehabilitation is equally effective as inpatient rehabilitation, often leading to greater patient satisfaction and lower healthcare costs. These insights reveal that structured conservative therapeutic interventions can optimize the recovery of patients with early and progressive arthritis, emphasizing the need for early perioperative considerations, as well as the potential for outpatient physiotherapy to yield similar results to traditional inpatient care.

Overall, Bridget offers a comprehensive overview of osteoarthritis management, advocating for an integrated approach that combines physiotherapy, education, and patient empowerment to enable individuals to regain their independence and improve their quality of life.

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Our next speaker is Bridget Dean. So Bridget is the lead physiotherapist of

the outpatient services and her clinical expertise lies in the management of back pain,

amputees and complex limb reconstruction surgeries.

She works closely with your other healthcare providers to provide multidisciplinary

care and she has a special interest in managing chronic back pain and she has

completed advanced cognitive functional therapy training.

She's an educator of the GLAD-BAC program and runs the program at Macquarie Health Physiotherapy.

Bridget has a background in education and she continues to teach in the Doctor

of Physiotherapy program and the

Doctor of Medicine degrees at Macquarie University. Thank you, Bridget.

Great. Thanks. So we're all here to talk about osteoarthritis.

And as physios, we like to make sure we keep things as simple as we can.

And that also means that we don't assume that people know anything.

So I'll start from scratch here as well.

So osteoarthritis is a common degenerative joint disease that affects millions of people worldwide.

As primary care providers, physios and GPs like yourself, play a crucial role

in detecting, providing patient education and management of this condition.

OI is primarily categorised as a breakdown of cartilage within the joints.

This generation is due in part to mechanical stress and the resulting inflammatory

response that accelerates the breakdown of the cartilage matrix.

The disease involves the entire joint structure, including subchondral bone

altercations, synovial inflammation and osteophyte formation.

Despite our cartilage having the ability to withstand copious amounts of physical

stress, it has a very poor ability to heal.

Therefore, when a joint is, sorry, when a joint has copious amounts of physical

stress and poor biomechanics,

excessive load bearing and trauma, in combination with other systemic risk factors

such as genetics, old age, and metabolic conditions such as diabetes,

these damaging forces within the joint often outweighs the joint's ability to repair.

And this mechanism leads to the development and progression of OA.

So OA affects a patient's quality of life, resulting in chronic pain,

stiffness, and decreased mobility.

These symptoms can lead to difficulties performing daily tasks,

reducing physical activity and subsequent social isolation.

Chronic pain often results in psychological effects such as depression and anxiety.

And a fear to continue to do their activities, which can further exacerbate

the decline of their quality of life.

As GPs, understanding these implications are vital to provide holistic care and pain management.

We encourage you to provide some recommendations for lifestyle modifications

and psychological support.

In addition to these multifactorial nature of osteoarthritis,

it's important to recognize the complexity of pain.

Pain serves as a warning signal to be interpreted by the brain and does not

always correlate directly with the degree of damage within the joint.

This means that an individual can experience significant pain with minimal joint

structure changes or conversely they can have advanced joints degeneration with very little pain.

While surgical intervention may ultimately be necessary as the damage to the

joint cannot be reversed, physiotherapy remains focused on managing the symptoms.

Today, I'll try and touch on how, as physiotherapists, we're involved in osteoarthritis.

By focusing on movement, weight management and structured physiotherapy programs,

we can help patients who have elected to undergo conservative management or

who are waiting to undergo elective joint replacement surgery take control of

their condition and improve their quality of life.

When managing OA, our approach is centered around five key principles.

Firstly, we aim to control symptoms like pain and stiffness to improve daily comfort.

Second, we focus on slowing the disease progression to preserve joint health for as long as possible.

And third, by maintaining and optimising function is essential.

Helping patients stay active and independent.

Fourth, we strive to enhance the quality of life by reducing pain and improving

mobility, while finally trying to ensure that we have effective use of the healthcare

system, which means that we're guiding patients towards the right treatments at the right time.

To achieve these goals, we incorporate five key components, education and self-management,

to try and empower the patient to take control of their condition.

Exercise, including supervised strength and cardiovascular training,

is crucial for joint support.

And weight management plays a significant role, as even a small reduction in

weight loss can ease joint stress.

Physiotherapy aids, such as offloading braces or walking sticks,

can provide additional relief and stability, while additional psychological

support helps patients navigate the challenges of chronic pain.

By combining these strategies, we can help patients manage OA effectively and

improve their overall well-being.

As a physiotherapist, we can

undergo training to run evidence-based education and activity programs.

One of the programs available is the GLAAD program, which stands with Good Life

Osteoarthritis Denmark.

It's a standardized evidence-based approach that helps manage hip,

knee, and now even back osteoarthritis.

It includes initial assessments, two group education sessions,

and 12 supervised education sessions over six weeks.

GLAAD has a formal research registry which includes functional outcomes,

outcome measurements, questionnaires, which allow us to track the patients.

The PEAK program, Physiotherapy Exercise and Physical Activity for Knee Arthritis,

was developed by the University of Melbourne.

It consists of five one-on-one physiotherapy consults that's delivered by either

in-person or via telehealth.

This program focuses on education, individualized strength in exercise,

and has a structured physical activity plan tailored to the patient's needs.

Both programs offered value, structured approach that empowers patients to manage their OA effectively.

Outside these two programs, the evidence is inconsistent for a prehabilitation

program, and this is because the types of programs vary significantly,

making it hard to establish best practice.

Overall, standardized guidelines are needed for both the intervention and outcome

measures, and this way we'll be able to determine what the actual effectiveness

of this prehabilitation can be.

Pre-operative physio can be done at home, in an inpatient facility,

or in an outpatient setting, with comparable outcomes of pain,

function, and quality of life across all these settings.

Generally, physiotherapy interventions should include low-impact aerobic activities

such as cycling or swimming, or high-intensity interval training with upper

limb ergometers for those that struggle to perform weight-bearing exercises.

The aim is to enhance cardiovascular fitness and promote weight loss.

Structured education programs can prepare a patient for surgery.

Explaining the expected outcomes, emphasising of post-operative adherence,

can improve the patient's expectations and their compliance.

Incorporating neuromuscular training can be useful to improve balance and coordination,

enhancing their functional outcomes post-operatively.

Overall, prehabilitation should ideally be performed months,

not weeks, before surgery.

Effective post-operative rehabilitation is crucial to optimise recovery post-joint replacements.

Early stages of recovery focuses on improving mobility, managing pain,

and regaining functional independence.

A comprehensive rehabilitation ensures a patient can progressively build strength,

increase range of motion, and safely regain mobility.

The key focuses are highlighted on the slide and are a central component to early rehabilitation.

Whether in an inpatient setting or in an outpatient home setting,

these approaches are aimed to optimise recovery outcomes and provide a continuum

of care throughout the patient's journey.

Starting with mobility exercise post-operatively day zero is crucial for facilitating

recovery following surgery.

Early movement encourages faster healing and supports the overall rehab.

Alongside this, proper prescription of walking aids and their gradual reduction,

in accordance to the surgeon's guidelines, ensures safe ambulation and reduces

risks and complications.

Gait training is another key component. By restoring natural movement and walking

patterns quickly after surgery, reduces a chance of developing abnormal loading.

Promoting independence with transfers and mobility is also essential.

When a patient can manage daily activities and tasks on their own,

it fosters a sense of autonomously and boosts their confidence in their rehab.

Managing pain and swelling effectively while closely monitoring the wound is

necessary to prevent further issues and support the healing process.

Graded exercises and range of motion are vital for improving our muscle strength

and our joint flexibility, while necessary depending on their pre-surgery functional levels.

Equally important is education.

As providing patients with clear instruction on movement precautions and what

to expect after surgery helps set realistic goals and encourages better adherence.

Lastly, ensuring a continuum of care across all stages of recovery from the

hospital to the outpatient setting is essential to make sure patients receive

the support they need and is essential for optimising their recovery outcomes.

When comparing home-based rehabilitation to inpatient rehabilitation,

studies have shown that there is no significant difference on functional recovery

or mobility between the two settings.

Patients report similar levels of satisfaction, whether they undergo rehabilitation

in the home or in the hospital, indicating that both approaches are equally

effective in meeting recovery goals.

One of the key advantages of home-based rehabilitation is that the patient can recover at home.

It means that this is cost-effective and in association with lower healthcare

costs while maintaining high care standards, making it an attractive alternative

for both patients and the healthcare system.

Additionally, opting for home-based rehabilitation often results in shorter hospital stays,

which can reduce the risk of hospital-acquired complications and supports a

quicker return to daily activities in a similar environment that they know and are comfortable in.

So overall summary for this is that conservative therapeutic approaches can

optimise patients with early and progressive arthritis.

Benefits of structured preoperative intervention include consistent education

and messaging and physiotherapy goals.

And the vast majority of patients are suitable and benefit from enhanced recovery

approaches to care, with discharge from home and outpatient physiotherapy having similar results.

Then early consideration for perioperative aids at home would be very useful

and that's something that you guys can help us with.