clinical guideline, singapore, osteoarthritis
There are only 22 clinical guidelines in Singapore that are available to the public. It is unsure if there are other guidelines available to medical doctors only. If so, Singapore has a long way to go in moving away from authoritative, doctor-centred care to embracing patient-centred care.

We have an ageing population here in Singapore so naturally there is a lot of concern when it comes to hip pain or knee pain.

Interestingly enough, the Ministry of Health’s website doesn’t include a current knee or hip osteoarthritis guideline. The only clinical practice guidelines for osteoarthritis of the knees was published in 2007 and has since been withdrawn.

Luckily for us, there are other countries in the world with up-to-date and openly published clinical guidelines.

Today, we will look at the 2010 Dutch guideline for physical therapy (PT) in patients with hip or knee osteoarthritis that was updated earlier in July this year (2020).

How to diagnose hip or knee osteoarthritis?

knee pain, hip pain, how to diagnose

If you are experiencing knee pain or hip pain and you are unsure if you are suffering from osteoarthritis, the diagnostic criteria may be useful in providing some insight.

Be mindful that meeting the criteria above doesn’t confirm you have osteoarthritis.

It may also be useful to note at this stage that clinical findings and radiographic findings (x-ray, MRI, etc) correlate very poorly in osteoarthritis. There are many, many people who show osteoarthritic changes in their x-rays and MRIs with absolutely no symptoms. You can read more about this phenomenon at osteoarthritis of the spine and knee arthritis.

I like clinical guidelines because they are written to address specific questions. For this edition, the guideline looked at the following questions:

1. Is exercise therapy recommended for people with hip osteoarthritis?
2. Is exercise therapy recommended for people with knee osteoarthritis?
3. Is exercise therapy recommended prior to joint replacement surgery for hip osteoarthritis?
4. Is exercise therapy recommended prior to joint replacement surgery for knee osteoarthritis?
5. Is exercise therapy recommended after joint replacement surgery for hip osteoarthritis?
6. Is exercise therapy recommended after joint replacement surgery for knee osteoarthritis?
7. Are the following non-exercise therapeutic interventions recommended for people with hip or knee osteoarthritis: continuous passive motion (after joint replacement surgery), pulsed electromagnetic field therapy, low-level laser therapy, massage, passive mobilisations, shock wave therapy, taping, TENS, thermotherapy, and ultrasound therapy?

For this blog post, I will only discuss questions 1, 2, and 7.

How can I exercise with a bad hip?

This is probably one of the most commonly asked question when it comes to hip pain. The question is not limited to older adults. Even middle-age pain suffers in their 40s are questioning their capacity to exercise.

Among seniors, there is a concern that walking may worsen osteoarthritis.

Thankfully for us, we have the 2020 Dutch clinical guideline to shed some light on these concerns.

Their recommendation? Exercise is STRONGLY recommended to ALL patients with hip osteoarthritis.

You may be surprised to learn that exercise is good for hip osteoarthritis. However, this is hardly news. Studies have already reported the benefits of exercising in providing osteoarthritic pain relief since as early as 1998!

That is not to say you can rush straight into running a marathon or a CrossFit WOD. The guideline also specifically highlighted for patients to take into consideration exercise frequency, intensity, time, and type (FITT principles).

What exercise is best for hip pain?

hip
If you Google “hip osteoarthritis exercises”, you will find lots of exercise resources — from exercise programs to YouTube videos — for hip pain. But the question remains, “What exercise is best for osteoarthritis?”

The Dutch guideline took reference from data compiled in a 2014 study published in crème de la crème Cochrane Review — Exercise for osteoarthritis of the hip.

In this systematic review, high quality evidence was found to support land-based exercises for both pain relief and also improved physical function.

I find “what is the best exercise for …” questions terribly unfair because that’s kinda like asking what is the best vegetable to eat?

While a high-fibre diet will do you good, there really isn’t necessarily a best vegetable per se — not in any meaningful way at least.

Similarly, there is no single best exercise for hip pain.

Hip pain patients may choose to engage an evidence-based chiropractor or physiotherapist to work with during this challenging period.

A 2013 study recommended a supervised and individualised exercise program of 6 to 8 sessions, which covers both flexibility and strengthening exercises.

Patients may start with exercises in non weight-bearing positions (e.g. seated, lying on the back) before progressing to functional movements such as sit-to-stand or squatting.

The gluteal muscle group was specifically identified as a key region to target as muscle wastage/loss in these muscles is common among hip osteoarthritis patients.

The study also specifically encouraged patients to walk, cycle, or swim for 30 minutes/day for at least five days a week!

These studies are not alone in making such recommendations. American College of Sports Medicine recommends 30 to 60 minutes of aerobic exercise a day for at least 3 to 4 days per week for patients living with osteoarthritis

In summary, you can exercise with a “bad” hip and exercise is likely to help improve both your symptoms and physical function.

For those with concerns about walking, please be assured that walking is a safe exercise for osteoarthritic pain sufferers (FITT principles).

What can be done for arthritis in the knee?

ultrasound therapy, physiotherapy singapore
While physiotherapy is often associated to be more evidence-based, this is not always true. Despite the lack of evidence to support ultrasound therapy as a treatment options, many physiotherapists in Singapore still offer it.

By this stage it should come as no surprise that exercise is strongly recommended for patients with arthritis in the knee. Again, exercise therapy is recommended for ALL knee arthritis patients.

If you are struggling to accept this, perhaps take a few moments to reflect why are you feeling this way.

What in exercising being good for arthritis is challenging your own beliefs?

To understand beliefs and how they work better, read my earlier post on role of beliefs in body and pain (based on a study published just last month).

How do I know if my knee injury is serious?

knee x-ray, healthy knee
knee arthritis, knee degeneration, x-ray

I think most people with knee pain or knee x-rays are worried about how bad their knee “damage” is.

Because x-rays allow you to see the structural changes — that you will otherwise be unaware of — we tend to fixate on it.

“Shucks, there’s no more space in my knee joint. I won’t be able to walk pain-free again. Ever.”

Well, the good news is that is simply not true.

First, we already have research to tell us that exercise can help with both your pain and function.

Second, I have real life cases to illustrate my point!

In the images above, you can see a healthy knee x-ray (left) and a knee x-ray of a 57-year old patient with “degenerative” findings (right).

If you are already thinking that this lady lived in pain and needs a surgery or total knee replacement, you are right.

This patient did live with knee pain for most of her adult life since an injury during her teenage years.

Since her early 40s, her knees already started showing signs of severe “degeneration”. She was also sedentary and overweight.

At the time of the x-ray, she described her knee pain as 9/10.

It comes as no surprise that she was put on the wait-list for a knee replacement surgery.

Here is where the miracle — or really just science — happened: she started exercising under supervision and after a year she described her pain as 1/10.

In fact, she recovered so well that she opted out of surgery. She didn’t need to go under the knife anymore.

How can I fix my knee pain without surgery?

The short answer is exercise. You can fix your knee pain without surgery if you exercise — preferably supervised by an evidence-based chiropractor or physiotherapist.

If the patient in the “damaged” knee case can exercise her way out of surgery to pain-free living, why can’t you?

Take a few moments to consider:

• If exercise worked despite how her knee looked on x-ray, her age, and her high BMI score, would it not work for her when she was younger?
• If “degeneration” or “wear and tear” is really the end of the road / there’s nothing else to be done, why did her pain improve from 9/10 to 1/10 — enough for her to remove herself from the knee replacement wait-list? Do you truly need surgery?
• What would her quality of life be like if she started working with an evidence-based professional in her 20s, 30s, or even 40s? How many more pain-free years could she add to her life?

You see, sometimes it is not that treatment or exercise doesn’t work. It is our disbelief or false beliefs that send us running to the wrong treatments. 

This is why I choose an evidence-based approach. It’s not about what you think or believe. It is also not about what I think or believe. It’s about what is most likely to give you the best outcomes.

What is the best treatment for knee pain or hip pain?

ultrasound therapy, knee osteoarthritis
Expensive treatments come with education diagram that looks fancy and seems to “make sense”. However, these mechanisms are theoretical plausibilities. Research do not support ultrasound therapy or shockwave therapy as effective for osteoarthritis of the knee and hip. Source: National Science Foundation

A lot of pain sufferers are focused on finding the best treatment or making the right decision when it comes to their pain management.

Let me let you in on a secret: There is no single best treatment. It’s about doing more of what works and less (or none) of what doesn’t work. 

According to the 2020 clinical guideline, here is what you should know about treatments that do not work:

• Massage therapy has a small benefit to physical function and pain relief for knee osteoarthritis. However, the quality of evidence is very low. As for osteoarthritis in the hip, the effect is UNKNOWN.

• TENS treatment has no effect on the no effect for knee pain and function in osteoarthritic patients. The benefits to patients with hip osteoathritis is UNKNOWN.

• Similarly, for shockwave and ultrasound, there are small to no effects.

The clinical guideline is firm recommending against massage, shockwave therapy, and ultrasound therapy.

 

Exercise alone may not be enough

Three steps to changing the narrative about knee osteoarthritis care: a call to action Source: British Journal of Sports Medicine

Beyond the exercise questions the clinical guideline attempt to answer, you should also know that a whole-person approach to managing arthritis will deliver superior results.

As seen in this infographic (published Feb 2020), recovery from arthritis encompasses more than just exercise.

Any high value care should include exercise, evidence-based education, and a lifestyle change. This is 100% congruent with the high performance pain solutions I offer at my practice.

I also want to heavily emphasised that false beliefs is not going to lead you to treatment success.

All the broscience and false narratives have to go:

Damage DOES NOT equal pain
Exercise is NOT dangerous
Rest is not a viable pain solution
Surgery is not the last resort fix-all answer

If you are living with osteoarthritic hip pain or knee pain, and would like to avoid or delay orthopaedic surgery, book in for an appointment with me to discover the difference the right care can make. At Square One Active Recovery, I offer a true whole-person treatment approach to helping you find freedom from pain.

 

Your Recovery Journey Begins Now

Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, chiropractor Jesse Cai founded Square One Active Recovery to deliver recovery goals in just 4 to 7 visits.

Not getting results from your chiropractor, TCM doctor or physiotherapist? Book an appointment to discover the difference the right care can make.

*We do not offer short-term pain solutions such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.

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