Osteoarthritis

For someone with severe osteoarthritis, the experience of long-term pain and limited activity may have a psychological impact, perhaps even leading to depression and anxiety. Loneliness and feelings of helplessness make pain worse. Self-care approaches and psychological treatments can help people cope better with pain and disability, and may improve quality of life.

You should always look for a practitioner who is properly trained and registered with the relevant professional body.

A lot can be done to help you manage your pain and preserve your social networks, to control your weight and overcome some of your physical limitations. When you see your GP or practice nurse, don’t just talk about your pain. Let them know if osteoarthritis is making relationships and activities difficult. And let them know if you think your overall wellbeing is suffering, or that you might be getting depressed or anxious. A comprehensive treatment plan can include treatment and self-care to help you get on with your life despite osteoarthritis.

Not all physical therapists use their hands; some are more exercise-based. Manual therapies can involve sessions of light or deep massage, with or without stretches. Osteopaths and chiropractors generally use stretching and manipulation of joints, as well as massage.

NICE (National Institute of Clinical Excellence) guidance on osteoarthritis suggests that manipulation and stretching should be used as ‘add-ons’ to core treatment, particularly for osteoarthritis of the hip. See below for some treatment options that it may be useful to try.

Summary
Acupuncture is a traditional form of treatment that began in China thousands of years ago. Thin needles are inserted into the skin at special points on the body, which practitioners believe will help restore health. The treatment sometimes also involves heat, pressure, electrical currents or soft-laser light. In the UK, acupuncture is most commonly used for pain relief.

Evidence
Acupuncture may help reduce arthritic pain and stiffness. The effects are small but they may make a useful difference for some people. There is good evidence that it can help with various sorts of long-term pain.

Safety
Acupuncture is generally safe if practised by a trained acupuncturist. The most common side-effects are slight discomfort (common) and bruising (occasionally).

Cost
A session may cost £40-£60. Frequency of treatment will depend on you and your practitioner.

Find out more
The following professional organisations can help you find a qualified practitioner:
Acupuncture Association of Chartered Physiotherapists
British Academy of Western Medical Acupuncture
British Acupuncture Council
British Medical Acupuncture Society

Summary
Even if osteoarthritis only affects one joint, it can reduce your mobility and your independence. The emotional effects of this can lead to depression. And the research suggests that people with osteoarthritis are more likely to get depressed.

You are more likely to get depressed:

– the worse your pain feels
– the fewer social contacts you have
– the harder you find it to get around
– the harder you find it to use your upper body
– the older you are
– the more overweight you are.

In a big US study, patients with osteoarthritis and depression were treated with anti-depressants and psychotherapy. Both their depression and their arthritis symptoms improved. The results showed that, after treatment, the participants had less pain and their arthritis caused less interference with their daily activities. Their general health status and quality of life improved as well.

Signs of depression
You might think that feelings of depression don’t have anything to do with having osteoarthritis. But please don’t ignore them. And if you think you could be depressed, getting help will make a huge difference. For more on this, see our section on Depression.

The following checklist of symptoms is only meant to help you discuss your concerns with your doctor and find out about different treatment options. Don’t be scared if you recognise the thoughts and feelings listed.  There are good treatments available to help you get through it and back to feeling well again.
Symptoms of depression include:

– sadness throughout the day, nearly every day
– loss of interest in your favourite activities
– feelings of worthlessness
– excessive or inappropriate feelings of guilt
– thoughts of death or suicide
– trouble making decisions
– fatigue or lack of energy
– sleeping too much or too little
– change in appetite or weight
– trouble concentrating
– feelings of restlessness or being slowed down.

If you have been experiencing some of these symptoms for more than two weeks, you ought to get some professional advice. If you are feeling as if you can’t cope, or that life is just too difficult or not even worth living, get help immediately. These are urgent signs that you need to talk to someone.

Evidence
There is good evidence that treating depression helps osteoarthritic pain and disability and improves all-round quality of life. CBT can help in depression, though not everyone benefits from this type of treatment.

Safety
These techniques are safe in most people if carried out by or under the guidance of a qualified counsellor or psychologist.

Cost
CBT can be expensive if you pay for it privately. It is widely available on the NHS though waiting times can be long. Ask your GP if it would be an appropriate treatment for you.

Further information
To find a trained psychotherapist near you check the relevant register of the British Psychological Society.

Summary
The Royal College of Psychiatrists says cognitive behavioural therapy (CBT) can help you change how you think (‘cognitive’) and what you do (‘behaviour’). Instead of looking for causes of distress in the past (as some forms of psychotherapy do), CBT looks for ways to improve your state of mind right now. It aims to help you find ways of reducing insomnia, anxiety, tension and depression.

There is good evidence that CBT can help reduce pain, as well as sleeplessness and depression in people with osteoarthritis.

Pain is stressful; and stress makes pain worse. Relaxation techniques are the most basic form of CBT. A CBT practitioner can also help you make sense of what may seem like overwhelming problems by breaking them down into smaller parts. This makes it easier to see how they are connected and how they affect you.

There are usually three phases in CBT for pain management:

1. learning about how pain is affected by thoughts, feelings and relationships;
2. training in relaxation techniques, activity pacing, scheduling, imagery techniques, positive breaks, using distraction, changing negative thought patterns, problem-solving and goal-setting;
3. trying out the new skills and applying them in real-life situations.

The ultimate aim of effective CBT is ‘active coping’. Active copers know how to go about solving problems and finding information. They get help from friends, family or professionals when they need it. When they feel stressed ‘physically or emotionally’ they have ways of dealing with it. Active coping is the opposite of ‘avoidant coping’. Avoidant copers try to avoid dealing with stressful situations or events by getting into damaging activities (such as over-use of alcohol) or negative mental states (such as withdrawal and isolation).

A recent review of the best clinical studies of psychological treatments for people with osteoarthritic pain looked at CBT (mainly skills for coping with pain) as well as biofeedback, stress management, emotional disclosure, hypnosis and psychodynamic therapy. The researcher concluded that these methods can reduce and prevent pain and suffering by helping people learn to cope better with anxiety, pain, depression, joint swelling and physical limitations. These coping skills improved their quality of life.

Evidence
Overall, psychological treatments had a small, but significant, effect on arthritis pain. These treatments were particularly effective in helping people learn active coping techniques, deal with anxiety and cope with joint changes.

Safety
These techniques are safe in most people if carried out by or under the guidance of a qualified counsellor or psychologist.

Cost
CBT can be expensive if you pay for it privately. It is widely available on the NHS though waiting times can be long. Ask your GP if it would be an appropriate treatment for you.

Further information
To find a trained psychotherapist near you check the relevant register of the British Psychological Society.

Summary
About 60% of people with osteoarthritis experience pain in the night. Pain disturbs sleep, and disturbed sleep makes pain worse in the long run. It’s a vicious circle.

Cognitive-behavioral therapy for insomnia (CBT-I) uses various methods to help develop positive attitudes and habits that promote a healthy sleep pattern. One common technique is relaxation training.

In one study, 23 older adults with osteoarthritis and insomnia (aged 69 on average) had eight CBT-I sessions, each lasting two hours once a week in classes ranging from four to eight people. After treatment they fell asleep faster, and spent less time awake during the night.

Evidence
A year after the research described above, the participants were still sleeping better and for 30 minutes longer each night. They reported less pain during the month after the CBT sessions ended; and a mild reduction in pain was reported one year later.

Safety
These techniques are safe in most people if carried out by or under the guidance of a qualified counsellor or psychologist.

Cost
CBT can be expensive if you pay for it privately. It is widely available on the NHS though waiting times can be long. Ask your GP if it would be an appropriate treatment for you.

Further information
To find a trained psychotherapist near you check the relevant register of the British Psychological Society.

Summary
Because you feel stiff and sore, you are likely to become less active. But then you lose fitness and strength. So don’t let having osteoarthritis put you off taking exercise. Keeping active will rebuild your muscles, and this will gradually protect your joints and reduce your pain. Getting active will also improve your mood and morale.

Structured exercise programmes generally take place in a group, supervised by a physiotherapist or qualified exercise instructor. Exercises should include aerobic activity as well as strengthening, posture-improving and stretching movements. A programme or course usually means eight or so sessions over 12 weeks, with exercises to practise at home between sessions.

Supervised exercise programmes are safe for most people. But at first you might feel more tired. If you are not used to doing much exercise, you should gradually increase your activity until you can manage a moderate level. If you feel worse, cut back and build up more slowly. If you think it isn’t helping or that you are getting worse in any way, check with your doctor. Anyone with severe osteoporosis, joint problems, acute back pain or recent injuries should avoid strenuous exercise.

Exercise training can include aerobic forms such as stepping and walking; strengthening exercises such as lifting weights or using resistance machines; and stretches for flexibility. Other types of exercise are tai chi, qi gong and yoga (see below).

Evidence
Research suggests that exercise eases knee pain and stiffness as much as anti-inflammatory medication. But it is not clear which type of exercise is best. Exercise, whether on land or in the water, definitely seems to help osteoarthritis of the knee and hip. The evidence is less certain about its effectiveness for osteoarthritis in other joints.

Safety
Supervised exercise programmes are safe for most people. Anyone with severe arthritis, osteoporosis, acute back pain or recent injuries should avoid strenuous exercise. If you haven’t been active for some time, start slowly and build up. If you have heart or chest problems, get medical advice first

Cost
There will probably be a small cost (around £10 a class) if you join an organised programme. Your GP can also refer you to the local physiotherapy department.

Further information
Classes and exercise programmes are run in most areas by both local authority leisure services and private gyms.

Summary
There are many different types of massage, some more vigorous and going deeper into the muscles than others. Massage has traditionally been used for relaxation. It may be just on one part of the body (for example, the back and shoulders), or it can be done on the whole body. Aromatherapy massage uses pleasant-smelling essential oils.

Evidence
Massage can ease back and neck pain but it is unclear whether or not it is helpful in osteoarthritis.

Safety
Massage is safe if carried out by qualified massage therapists, and it rarely causes problems. Vigorous massage should be avoided if you have blood disorders, some forms of cancer, skin problems or are on blood-thinning medications (such as warfarin). Allergies or skin irritation can occur with some essential oils used in massage.

Cost
Monthly cost will depend on how regularly you receive treatments.

Further information
It is important to find a qualified practitioner such as one registered with The General Council for Soft Tissue Therapies.

Summary
Physiotherapists use exercises and stretches to improve strength, flexibility and stiffness. Often these exercises need to be done at home at least once daily for many weeks or months. Some physiotherapists can provide massage, hydrotherapy in a special pool, many use soft lasers, electrotherapy or ultrasound to speed up healing. A lot of physiotherapists use acupuncture techniques as well. Ask your physiotherapist what sort of methods they have available.

Evidence
Physiotherapy is important in the management of OA. For instance learning the right exercises for strengthening the thigh muscles will reduce pain and stiffness of the knees. Regular aerobic and resisted exercises can improve all round levels of pain.

Safety
Physical treatments are generally safe if practised by a trained therapist.

Cost
The exercises are simple, but they need to be done every day. They cost nothing once you have learned to do them. However you need advice for the right exercises and your GP may refer you to an NHS physiotherapist. Private physiotherapy is available in all areas. A half hour appointment will vary in cost between £30 and £60. Monthly cost will depend on duration of the treatment.

Further information
It is important to find a qualified practitioner such as one registered with  The Chartered Society of Physiotherapy.

Summary
Tai chi is also known as ‘moving meditation’ It is a series of slow, graceful, controlled movements, which develop strength, balance, posture and inner peace. It is a discipline that has to be learned in a class from a teacher and can then be practised at home.

Evidence
There is some research suggesting that tai chi can help people cope with painful knee joints.

Safety
Tai chi is safe for most people. Though it is slow and gentle, anyone with severe osteoporosis, joint problems, acute back pain or recent injuries should avoid strenuous exercise and build up gently.

Cost
Once you have learned the movements, you can do the exercises at home, at no cost.

Further information
Classes are run in most areas by both private tutors and by adult education services or you can contact the The Tai Chi Union.

Summary
Yoga, as taught in the UK, generally includes physical postures or stretches, breathing techniques, meditation and relaxation. There are several different types of yoga. Some of them are mainly based on the physical exercises (some types are much more strenuous than others). Others focus more on meditation.

Evidence
Yoga exercises may help if you have been told that your low back pain is due to osteoarthritis. But there isn’t much research to support it as a self-care treatment for osteoarthritis in general, apart from one study which showed that it helped with osteoarthritis in the hands.

Safety
Yoga is generally safe when practised appropriately and at the right level. Classes are run for different ability levels so look for one that is right for you. Yoga stretches should be increased slowly. If in doubt, check with your doctor, osteopath or physiotherapist. Avoid with severe osteoporosis or acute joint or back pain, or recent injuries.

Cost
You will have to pay for the classes but once you have learned this technique you can practise it at home at no cost.

Further information
Classes are run in most areas by both private tutors and by adult education services. To find a qualified teacher near you see also the The Yoga Alliance
and the The British Wheel of Yoga.