PHYSIOTHERAPY TREATMENT OF OSTEOARTHRITIS PATIENTS

26. March 2021

physiotherapy treatment of osteoarthritis patients

Effective physiotherapy is a cornerstone of managing osteoarthritis, a common condition affecting millions in the UK. Osteoarthritis (OA) is a condition where joints can become painful, stiff, and swollen. It is the most prevalent form of arthritis and a leading cause of mobility-related disability, particularly in older adults. Historically, OA was often dismissed as simple “wear and tear,” an inevitable consequence of ageing that one must simply endure. This outdated view fosters a sense of helplessness and can lead to a fear of movement, which paradoxically worsens the condition. Modern medical understanding, however, presents a more accurate and empowering picture.

Osteoarthritis is now recognised as a complex, active condition of the entire joint—including cartilage, bone, ligaments, and surrounding muscles. It results from an imbalance in the body's natural processes of damage and repair. When cartilage becomes worn, the tissues within the joint become more active as the body attempts to heal itself. Sometimes this repair process is successful, but in OA, the structural changes can lead to the characteristic symptoms of pain and stiffness.

This fundamental shift in understanding—from passive degeneration to an active biological process—is crucial. It transforms the individual from a victim of inevitable decline into an active participant in their own care. Recognising that the body is trying to repair the joint makes it easier to understand how targeted interventions, particularly therapeutic exercise, can support and enhance these natural processes rather than cause more harm. This proactive mindset is the foundation of modern and effective osteoarthritis management.

The condition is extremely common, likely to affect most people as they get older, though it can also affect younger individuals, often following a joint injury. It most frequently affects the hands, feet, hips, and knees. The societal burden of OA is substantial and is projected to increase significantly. In the UK, it is estimated that the number of people seeking treatment for osteoarthritis could rise from 4.71 million in 2010 to 8.30 million by 2035, driven by the nation's ageing population and the increasing prevalence of obesity.

What are the Common Symptoms and Causes of Osteoarthritis?

Recognising the Symptoms: Beyond Just Pain

In the UK, the diagnosis of osteoarthritis is typically made clinically, based on a distinct pattern of symptoms, without the need for routine imaging like X-rays. This approach, recommended by the National Institute for Health and Care Excellence (NICE), provides clarity for patients and avoids unnecessary procedures. The key diagnostic criteria for individuals aged 45 or over are:

Activity-related joint pain.
Either no morning joint-related stiffness, or morning stiffness that lasts for no longer than 30 minutes.

This specific pattern helps differentiate OA from other forms of arthritis, such as rheumatoid arthritis, which often involves prolonged morning stiffness. It is important for individuals to understand that the severity of symptoms does not always correlate with what is seen on an X-ray; minimal visible changes can be associated with substantial pain, and vice versa.

Beyond these core diagnostic symptoms, individuals with OA may experience a range of other signs. A grating or crackling sound or sensation, known as crepitus, may occur when the joint is moved. The joint may not move as freely as it once did, and the surrounding muscles can sometimes appear wasted or thin. Some people experience episodes where the joint "gives way," which can be due to muscle weakness or a loss of structural stability within the joint itself. In some cases, visible changes can occur, such as the formation of firm, knobbly bony growths called osteophytes at the joint edges, which are particularly common in the finger joints.

A crucial aspect of living with osteoarthritis is understanding its fluctuating nature. Symptoms are often variable, leading to what many describe as "good days and bad days". A common experience is a "flare," which is a temporary but significant worsening of symptoms. During a flare, pain, swelling, and stiffness can intensify to a level that is worse than normal, potentially affecting sleep, daily activities, and psychological wellbeing. Recognising that these fluctuations are part of the condition can help individuals develop strategies to manage the more difficult periods without becoming discouraged.

Understanding the Causes and Risk Factors

The precise cause of osteoarthritis remains unknown, but research has established that it is a multifactorial condition, arising from a complex interplay of genetic and lifestyle factors. It is not caused by normal activity or exercise. Key risk factors identified in UK-based research include:

Age: The likelihood of developing OA increases significantly from the late 40s onwards. This may be due to age-related changes in the body, such as weakening muscles and a reduced capacity for self-repair.
Gender: For most joints, particularly the knee and hand, osteoarthritis is more common and often more severe in women than in men.
Obesity: Being overweight is one of the most significant modifiable risk factors, especially for weight-bearing joints like the knee and hip. Research from Versus Arthritis highlights a stark reality: obese individuals are up to 14 times more likely to develop knee OA than those of a healthy weight. Excess weight contributes to OA in two ways: it increases the mechanical load and stress on the joints, and fat tissue itself produces inflammatory chemicals that can degrade cartilage.
Genetic Factors: Genetics play a substantial role, with heritability estimated to account for around 50% of an individual's risk of developing hip or knee OA. This genetic link is particularly strong for osteoarthritis in the hands. Major UK-led research, such as the arcOGEN study, has successfully identified several new genetic regions associated with the condition, some of which are involved in how joints are made and maintained, opening new avenues for future treatments.
Joint Injury or Overuse: A previous major injury, such as a fracture or ligament tear, or surgery on a joint can lead to the development of post-traumatic OA in that joint later in life. Similarly, certain occupations involving very hard, repetitive physical activity can increase the risk in specific joints. For instance, farming has been linked to hip OA, while underground mining and professional football are associated with knee OA.
Other Joint Diseases: Osteoarthritis can sometimes develop as a secondary consequence of damage from another type of joint disease, such as rheumatoid arthritis or gout.

One of the most critical messages for anyone diagnosed with OA is to challenge the deep-seated myth that exercise causes or worsens the condition. This fear is a major barrier to effective self-management, as it leads to activity avoidance, which in turn causes the very problems that exacerbate OA: muscle weakness, increased stiffness, and weight gain. The scientific evidence is unequivocal: exercise does not cause OA and is, in fact, a powerful preventative tool. Strong muscles act as shock absorbers, supporting and protecting the joints. Furthermore, research suggests that exercise can increase the level of natural anti-inflammatory chemicals inside the joints, which may help protect against cartilage loss and further damage. This understanding is essential for empowering individuals to engage confidently with the most effective treatment available to them.

What are the Treatment Options for Osteoarthritis in the UK?

The management of osteoarthritis in the UK is guided by a clear, evidence-based framework established by NICE. The 2022 guidelines (NG226) provide a "treatment hierarchy" that prioritises patient education and self-management, moving towards other interventions only when necessary. This approach helps manage patient expectations, shifting the focus from a "quick fix" to a sustainable, long-term strategy for health and wellbeing.

The foundation of this hierarchy rests on three core treatments that should be offered to all individuals with osteoarthritis, regardless of age, severity, or the joints affected:

Information and Support: The first step is providing high-quality, tailored education. This involves explaining what OA is (and what it is not), challenging common misconceptions (like the "wear and tear" myth), and guiding people on how to manage their symptoms, including flares. This empowers individuals with the knowledge and confidence to take an active role in their own care.
Therapeutic Exercise: This involves a personalised programme of exercises designed to strengthen the muscles around the affected joints and improve general aerobic fitness. As the cornerstone of OA management, its goal is to reduce pain, improve function, and enhance quality of life.
Weight Management: For individuals who are overweight or obese, weight loss is a critical intervention. NICE advises that losing even a small amount of weight is beneficial, but a target of 10% weight loss is likely to produce greater improvements in pain and physical function than a 5% loss. Every pound of weight lost removes four pounds of pressure from the lower-body joints, which can lead to a significant reduction in pain.

These core treatments are not optional extras; they are the primary, most effective strategies for managing OA in the long term.

When these core strategies are not enough on their own, or to help a person engage with them more effectively, other adjunctive treatments can be considered. The key principle is that pharmacological treatments are used to support exercise and activity, not replace them. They should be used at the lowest effective dose for the shortest possible time.

Recommended Pharmacological Treatments

Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): For knee osteoarthritis, NICE recommends offering a topical NSAID, such as an ibuprofen or diclofenac gel, to be rubbed into the skin over the joint. This can also be considered for other joints.

Oral NSAIDs: If topical treatments are not effective, an oral NSAID (e.g., ibuprofen or naproxen tablets) can be considered. However, due to potential side effects on the stomach, kidneys, and cardiovascular system, they should be prescribed alongside a gastroprotective medication like a proton pump inhibitor.

Treatments Used with Caution or Not Routinely Recommended

Paracetamol and Weak Opioids: NICE explicitly states that paracetamol and weak opioids (like codeine) should not be routinely offered for OA. There is a lack of strong evidence for their benefit, and they carry risks of side effects. They should only be considered for infrequent, short-term pain relief if all other options have failed.

Strong Opioids: Strong opioids (like morphine or tramadol) are not recommended for managing OA due to the significant risks of harm, addiction, and side effects outweighing the potential benefits.

Treatments Explicitly Not Recommended by NICE

Glucosamine and Chondroitin: Despite their popularity as over-the-counter supplements, NICE does not recommend glucosamine or chondroitin, as there is no strong evidence that they provide any benefit.

Intra-articular Hyaluronan Injections: These "lubricant" injections are also not recommended for the management of OA.

Other Interventions

Corticosteroid Injections: An injection of corticosteroid medication directly into the joint may be considered for short-term pain relief (typically lasting 2 to 10 weeks). This can be a useful strategy to reduce a severe flare-up of pain, enabling an individual to engage more effectively with their therapeutic exercise programme. However, repeated injections can be harmful to the joint in the long term, so their use is limited.

Surgery (Joint Replacement): For individuals whose joint symptoms are severely impacting their quality of life and for whom non-surgical management has been ineffective, a referral for joint replacement surgery (e.g., hip or knee replacement) is a highly effective option. It is important to note that NICE guidelines state that people should not be excluded from referral based on age, weight, or other health conditions. Physiotherapy plays a critical role both in preparing for surgery and in the rehabilitation process afterwards.

Seeking Treatment through Physiotherapy: Your Path to Better Movement

The Central Role of Physiotherapy Treatment

For anyone navigating the challenges of osteoarthritis, a physiotherapist is an essential expert partner. They are highly trained healthcare professionals who specialise in assessing, diagnosing, and managing musculoskeletal conditions. A physiotherapy treatment plan for OA is not a one-size-fits-all solution. It begins with a comprehensive assessment of an individual's joint movement, muscle strength, flexibility, balance, and overall physical function. This allows the physiotherapist to develop a personalised programme tailored to specific needs, abilities, and goals.

The role of the physiotherapist extends far beyond simply prescribing exercises. They provide crucial education about the condition, helping to dispel myths and build confidence in the body's ability to adapt. They teach self-management strategies, including "pacing," which involves balancing periods of activity and rest to avoid the "boom and bust" cycle of overdoing it on good days and suffering afterwards. By setting realistic, achievable goals and providing ongoing support and motivation, physiotherapists empower individuals to take control of their condition and remain active and independent.

Therapeutic Exercise in Detail: Building a Stronger Foundation

Exercise is consistently cited as the single most important intervention in the management of osteoarthritis. The fear that movement will cause further damage is not supported by evidence; in fact, the right kind of exercise is profoundly beneficial. It helps to reduce pain, improve posture, relieve stress, and can contribute to weight loss. A well-rounded physiotherapy treatment programme will incorporate a combination of exercise types to achieve the best results:

Strengthening Exercises: These are designed to build up the muscles that surround and support the affected joint. Stronger muscles act like a scaffold, absorbing shock and reducing the load that goes through the joint itself, thereby decreasing pain and improving stability.
Range-of-Motion and Stretching Exercises: These exercises focus on gently moving the joint through its full available range. This helps to reduce stiffness, improve flexibility, and prevent the joint from becoming "stuck."
Aerobic/Cardiovascular Exercise: This type of exercise, which raises the heart rate, is vital for overall health. Low-impact activities like brisk walking, swimming, or cycling are excellent for people with OA as they improve stamina and energy levels, help with weight management, and boost mental wellbeing without placing excessive stress on the joints.

To provide a practical starting point, the following table outlines some foundational exercises for knee and hip osteoarthritis, as recommended by NHS sources. It is essential to perform these movements in a slow, controlled manner and to listen to your body. A physiotherapist can ensure the technique is correct and progress the exercises appropriately.

Joint	Exercise	How to Perform (Simplified)	Starting Point	Key Tip	Source(s)
Knee	Sit to Stand	From a sturdy chair, stand up and sit back down slowly without using your arms for support.	2 sets of 8 repetitions	Make sure your bottom just touches the chair; don't sit down completely. Keep your back straight and knees aligned with your toes.
Knee	Lying Knee Bend	Lying on your back on a bed or floor, slowly slide the heel of your affected leg towards your bottom, bending the knee as far as is comfortable. Hold for 2 seconds, then slowly straighten.	2 sets of 8 repetitions	Keep the movement smooth and controlled. You should feel a gentle stretch, not sharp pain.
Knee	Static Quad Squeeze	Lying or sitting with your leg straight, tighten your thigh muscle (quadriceps) and gently push the back of your knee down into the surface.	Hold for 10 seconds, repeat 10 times	Focus on feeling a strong contraction in the muscle at the front of your thigh.
Hip	Bridging	Lying on your back with knees bent and feet flat on the floor, squeeze your buttock muscles and slowly lift your hips towards the ceiling. Hold for a few seconds, then lower slowly.	2 sets of 8 repetitions	Avoid arching your lower back; the movement should come from your hips.
Hip	Standing Hip Extension	Standing and holding onto a stable surface for balance, keep your affected leg straight and slowly lift it backwards.	2 sets of 8 repetitions	Do not lean your body forward. The goal is to isolate the movement to the hip and buttock muscles.
Hip	Clam	Lying on your side with your hips and knees bent and your feet together. Keeping your feet touching, lift your top knee upwards as far as you can without letting your pelvis roll backwards.	2 sets of 10 repetitions	Imagine you have a glass of water balanced on your hip to keep your trunk stable.

Hands-On and Advanced Therapies

In addition to exercise prescription, physiotherapists may use other techniques as part of a comprehensive treatment plan.

Manual Therapy: This involves hands-on techniques such as specific stretching, joint mobilisation, or soft tissue massage. These techniques can be very effective for reducing pain and improving joint flexibility, making it easier for an individual to then perform their exercises. In line with NICE guidance, manual therapy should be considered an adjunct to therapeutic exercise for hip and knee OA, not a standalone treatment.
Electrotherapy and Shockwave Therapy: The field of physiotherapy is constantly evolving, and it is crucial to use treatments that are supported by the best available evidence. This is particularly relevant when considering modalities like electro therapy and shockwave therapy.

Electro Therapy (TENS, Ultrasound etc.): For many years, various forms of electro therapy were common in physiotherapy clinics. However, the latest NICE guidelines (NG226) are very clear: modalities such as Transcutaneous Electrical Nerve Stimulation (TENS), therapeutic ultrasound, interferential therapy, and laser therapy are not recommended for the management of osteoarthritis. This recommendation is based on a thorough review of the scientific literature, which found insufficient evidence of clinical benefit for these treatments. While some individuals may report temporary relief, the evidence does not support their routine use within the NHS or in best-practice private care.

Shockwave Therapy (ESWT): In contrast, Extracorporeal Shockwave Therapy is a more modern, non-invasive technology that is showing significant promise for osteoarthritis, particularly of the knee. ESWT uses high-energy acoustic sound waves, delivered through a probe on the skin, to stimulate a healing response in the target tissue. The proposed mechanisms include increasing local blood circulation, stimulating tissue regeneration, and modulating pain signals. A growing body of high-quality research, including systematic reviews and meta-analyses, has shown that shockwave therapy can provide significant improvements in both pain and function for people with OA, with results often superior to placebo and even corticosteroid injections. A typical course involves 3-5 weekly sessions, and it is most effective when combined with a rehabilitation exercise programme.

Positive Effects in Practice: UK Case Studies

The principles of physiotherapy-led care for osteoarthritis are not just theoretical; they are delivering tangible, positive results for thousands of people across the UK.

Large-Scale Success: The ESCAPE-pain Programme: One of the most compelling UK case studies is the ESCAPE-pain (Enabling Self-management and Coping with Arthritic Pain through Exercise) programme. Developed by UK-based researchers and professors, this group rehabilitation programme integrates education and a progressive exercise circuit. It is specifically designed to be delivered in a variety of settings, from hospital physiotherapy departments to community leisure centres. The programme's success has been remarkable:

Proven Benefits: It is proven to reduce pain, improve physical function, enhance mental wellbeing, and reduce reliance on pain medication.

NICE Recommended: Its strong evidence base led to its recommendation in NICE guidelines.

Cost-Effective: It delivers significant savings to the NHS, with an estimated return on investment of £5.20 for every £1 spent.

National Rollout: The programme has been implemented in approximately 300 locations across the UK, helping tens of thousands of participants take control of their joint pain. This demonstrates how a well-designed physiotherapy treatment model can be scaled up to achieve population-level impact.

An Individual's Journey: The impact of physiotherapy is also powerfully illustrated at the individual level. Consider a composite case based on real-world scenarios: A 78-year-old man, a passionate sailor, presents to a First Contact Physiotherapist in his GP practice. He reports severe left hip pain that radiates down his thigh, rating it a 9 out of 10. His mobility is severely limited; he relies on a walking stick and finds it excruciating to sit. A thorough physiotherapy assessment, including specific tests for the hip and ruling out nerve-related back issues, strongly suggests severe hip osteoarthritis, a diagnosis later confirmed by an X-ray.

According to the NICE pathway, before a surgical referral is considered, a minimum of three months of non-surgical management is required. His physiotherapy treatment begins immediately. He receives education to understand his condition and is prescribed a tailored exercise programme focusing on strengthening the muscles around his hip (like gluteal bridges and hip extensions) and improving his walking pattern. He is also advised on using his walking stick correctly to offload the painful joint. If his pain is particularly severe, a single corticosteroid injection might be used to "calm things down" enough for him to engage with his exercises. Even if he eventually proceeds to a hip replacement, as another patient case study did, the journey with physiotherapy is paramount. That patient, after successful surgery, was walking with the help of a physio within an hour of the operation. Through a dedicated post-operative rehabilitation plan, he was walking without a limp in seven weeks and, by week ten, was enjoying long, brisk walks, feeling as though the surgery had "reversed his age". These cases highlight the central role of physiotherapy across the entire care pathway, from initial diagnosis and non-surgical management to pre-habilitation and post-operative recovery.

Conclusion

Osteoarthritis is a common and often challenging condition, but it is crucial to understand that it is manageable and not a sentence to inevitable decline. The outdated notion of simple "wear and tear" has been replaced by a more sophisticated understanding of OA as a dynamic condition of the whole joint, where the body's attempts at repair can be supported and enhanced. A proactive approach, grounded in the best available evidence, is the key to successfully managing symptoms and maintaining an active, fulfilling life.

The foundation of this proactive approach, as unequivocally supported by the highest level of guidance from the UK's leading health bodies, including NICE and the NHS, is a core strategy of personalised education, therapeutic exercise, and, where appropriate, weight management. Other treatments, such as medication or injections, play a supporting role, primarily to enable individuals to engage more fully with this foundational strategy.

Navigating this journey alone can be daunting. The role of a physiotherapist is to act as an expert guide, providing an accurate diagnosis, a tailored physiotherapy treatment plan, hands-on therapy, and the crucial education and motivation needed to achieve long-term success. They can help you understand your body, build strength and confidence, and implement strategies that have been proven to work. By working with a qualified professional, you can create a personalised plan to manage your symptoms and improve your quality of life through physiotherapy.

Frequently Asked Questions: Physiotherapy for Osteoarthritis

How quickly will I see results from physiotherapy for osteoarthritis?

Most patients notice some improvement in pain and mobility after 4-6 weeks of consistent physiotherapy treatment. Individual results vary based on severity, joint affected, and adherence to your prescribed exercise program.

Is physiotherapy for osteoarthritis covered by the NHS?

Yes, physiotherapy for osteoarthritis is available through the NHS with a GP referral or through self-referral in many areas. Some patients choose private physiotherapy to avoid waiting lists and receive more frequent sessions.

Can I do physiotherapy exercises at home, or must I visit a clinic?

Most physiotherapy exercises for joint pain can be performed at home after initial instruction from a qualified physiotherapist. Your therapist will create a personalized home exercise program and periodically reassess your technique and progress.

How often should I do my physiotherapy exercises for osteoarthritis?

Most physiotherapists recommend performing your prescribed exercises daily or at least 3-4 times per week for optimal joint health. Consistency is more important than intensity when managing osteoarthritis symptoms.

Are there specific dietary recommendations for managing osteoarthritis?

An anti-inflammatory diet rich in omega-3 fatty acids, fruits, vegetables, and whole grains may help reduce osteoarthritis inflammation. Some patients report benefits from reducing nightshade vegetables (tomatoes, potatoes, eggplants) and increasing turmeric consumption, though research evidence remains limited.

Can I continue playing sports with osteoarthritis?

Many people with osteoarthritis can continue sports with appropriate modifications and joint protection strategies. Low-impact activities like swimming, cycling, and walking are generally recommended, while high-impact sports may need to be limited based on your specific joint condition.

What qualifications should I look for in a physiotherapist for osteoarthritis?

Look for a HCPC-registered physiotherapist with experience in musculoskeletal conditions and osteoarthritis management. Physiotherapists with additional qualifications in pain management or specialized manual therapy techniques may offer additional benefits for complex cases.

Is hydrotherapy effective for osteoarthritis?

Hydrotherapy (water-based exercise) is highly effective for osteoarthritis as the buoyancy reduces pressure on painful joints while providing gentle resistance. The warm water also helps relax muscles and reduce stiffness, making it ideal for those who find land-based exercises challenging.

How do I manage osteoarthritis pain while traveling?

Pack portable pain relief options like heat patches, topical NSAIDs, and a collapsible walking stick, and remember to move regularly during long journeys. Consider booking accommodation with accessibility features and planning rest days between activities to manage fatigue and prevent flare-ups.

Can osteoarthritis be reversed or cured with physiotherapy?

Physiotherapy cannot reverse the structural joint changes in osteoarthritis, but it can significantly improve symptoms and function by strengthening supporting muscles. The right exercise program can effectively manage pain and potentially slow disease progression, allowing many people to avoid or delay surgery.

What's the difference between a physiotherapist and an osteopath for treating OA?

Physiotherapists typically focus on evidence-based exercise prescription and functional rehabilitation for joint pain, while osteopaths tend to emphasize manual manipulation techniques. Both can be effective for osteoarthritis management, though physiotherapy has stronger research evidence specifically for OA.

How should I modify my home to help manage osteoarthritis?

Install grab bars in bathrooms, replace round doorknobs with lever handles, and consider raised toilet seats and shower chairs for easier joint movement. Removing trip hazards and ensuring good lighting can prevent falls that might worsen joint damage.

What should I do during an osteoarthritis flare-up?

During a flare-up, temporarily reduce high-impact activities while continuing gentle range-of-motion exercises and applying ice or heat as needed. Consult your physiotherapist about modifying your exercise routine rather than stopping completely, as movement remains essential for joint health even during flares.

Are there assistive devices that can help with daily activities?

Numerous joint-friendly adaptive devices can help maintain independence, including jar openers, long-handled reachers, sock aids, and ergonomic kitchen tools. An occupational therapist can recommend specific aids based on your particular challenges and affected joints.

Is heat or ice better for osteoarthritis pain?

Heat often works better for morning stiffness and chronic pain by improving blood flow and relaxing muscles around affected joints. Ice is typically more effective for acute pain and inflammation after activity or during flare-ups, though individual preferences vary.

What types of footwear are best for people with osteoarthritis?

Supportive shoes with good arch support, cushioned soles, and a wide toe box help reduce impact on weight-bearing joints. Custom orthotic insoles may provide additional benefits for knee and hip osteoarthritis by improving alignment and reducing joint stress.