Several years ago, Jill (not her real name) was shortlisted for a total knee replacement at Sydney’s Royal North Shore Hospital.

With a 10-year history of knee pain, a diagnosis of a serious autoimmune condition, giant cell myocarditis, and after receiving a heart transplant, the 55-year-old was given another 10 years to live.

Jill also had steroid-induced type 2 diabetes, high blood pressure, Graves’ disease, Thyroidectomy, hypercholesterolemia and depression.

Wanting to avoid surgery, Jill was invited to participate in a new physiotherapy-led multidisciplinary program at the hospital targeting knee osteoarthritis patients on the elective surgery waiting list.

Under the program, which aims to reduce pain, increase mobility and improve quality of life, a physiotherapist prescribed a strength and aerobic-based program and enrolled Jill in a hydrotherapy program. A rheumatologist provided pain management options and a dietitian provided a weight loss and diabetes management program.

Thanks to the program, Jill’s health has been transformed - her function, pain and quality of life improved significantly. She lost 17kgs and eventually, under the guidance of her GP, no longer required two of her four cardiac medications. In addition, she stopped taking her anti-depressant medication, and reduced her diabetes medication.

Most importantly, Jill has returned to her work as a park ranger and is now doing what she loves most - walking her dog via a track to the bottom of the sea cliffs to reach her favourite cafe each morning.

It was a walk that previously took Jill 45 minutes, and she experienced considerable pain. Now, Jill completes the walk in just under 10 minutes, pain-free.

Jill’s incredible improvement showcases the benefits of exercise and weight loss for one of the most common, debilitating, costly and rapidly growing chronic conditions - osteoarthritis.

Now, exercise and weight loss have been cemented as key recommendations, and the first treatment options for knee osteoarthritis, in a new Clinical Care Standard for health practitioners.

New Clinical Care Standard

Surgery should be a last resort for treating knee osteoarthritis.

The new Osteoarthritis of the Knee Clinical Care Standard, released by the Australian Commission on Safety and Quality in Health Care and endorsed by the Australian Physiotherapy Association (APA), highlights increased exercise, weight loss and using pain-relieving medicines as the less invasive, best-practice option - the gold standard for high-quality care.

The standard states surgery should only be considered when a patient’s symptoms fail to respond to more conservative management.

It also discourages the use of one common form of treatment - arthroscopy, unless patients are experiencing a mechanical locking of the knee.

A chronic disease of the synovial joints, osteoarthritis eventually leads to a wearing away of the lining inside the knee. The condition often results in significant pain and disability.

Almost one in five Australians has arthritis and many of those have osteoarthritis, which affects more than a quarter of people over the age of 65. Statistics also show overweight patients have double the risk of developing knee osteoarthritis while obese patients have four times the risk.

Senior physiotherapist Matthew Williams, an APA member who was part of the Clinical Care Standard working group, says the standard reinforces the crucial role physiotherapists play in the management of knee osteoarthritis.

“It’s hopefully going to alert GPs of the fact that there are alternatives to referring patients solely to an orthopaedic surgeon, and therefore we are going to have hopefully more of an opportunity to employ the evidence-based methods that patients can benefit from,” he says.

APA calls for better funding

The APA fears patients may take the cheaper option of having surgery than following the recommended physiotherapy treatments for knee osteoarthritis, highlighted in the new Clinical Care Standard.

The peak physiotherapy body says patients following the recommended conservative management options by physiotherapists will run out of cover under Medicare and their private health insurance.

National president Phil Calvert says the system is fundamentally flawed, and he’s called for Medicare and private health insurers to review their funding models.

“It is nonsensical that consumers who rightly opt to manage their OA symptoms via self-management with specific exercise programs provided by highly experienced and qualified physios, as well as other lifestyle modifications, should be worse off than those who choose surgery and all the potential risks that entails,” he says.

A physiotherapy-led program

Mr Williams is the musculoskeletal coordinator of the Royal North Shore Hospital’s osteoarthritis chronic care program, and the clinical lead of the district osteoarthritis chronic care program.

The model of care, implemented at the hospital in 2012, is a multidisciplinary team intervention, comprising a rheumatologist, dietitian, occupational therapist, social worker, and an orthotist, for patients with significant knee and hip osteoarthritis.

Under the initiative, Mr Williams works with each patient to establish a set of individual goals.

“We really want the patients engaged in the sorts of activities that they enjoy, and we want them to really bring forth the type of things that they want to achieve - so the goals are meaningful to them with us kind of steering them towards the things that will be most beneficial.”

Mr Williams says the program has been a success - achieving a 15 per cent reduction in the number of patients joining the elective joint replacement list, alongside statistically significant improvements in pain, function, mobility, and quality of life.

“Through all of the different management strategies that we employ on our patients, we’ve seen even end-stage arthritis sufferers…actually coming off those waiting lists,” he says.

“And when we evaluated two years down the track to see what percentage of those had returned to the waiting list, only nine per cent of those had.

“So the improvements derived from being on our program over a nine to 12 month period, whilst patients were waiting for their surgery, were being sustained at least two years down the track - that’s certainly fantastic.

“We are also seeing clinically significant improvements in weight loss for the patients that come through our program, which is a cohort which traditionally can tend to put on weight because they become very sedentary.”

The program dispels misconceptions that exercise is damaging to osteoarthritis, and delivers education to show that exercise is essential to managing the condition.

Mr Williams says the program is much more than an osteoarthritis program - it’s a chronic disease management program.

He says it also empowers patients, equipping them with the knowledge and tools to be able to self-manage their osteoarthritis.

“Seeing the fear leave their eyes when it comes to talking about exercising and re-engaging in activities…being able to reverse that is extremely satisfying,” he says.

“The patients have transformed their lives - have transformed the way they approach their health, rather than being victims they see themselves as stronger, more confident, more adaptive, almost problem-solvers.

“So that’s what’s probably the most satisfying thing for me - giving the power back to those patients and instilling confidence and self-belief, and giving them realistic management options that are evidence based.”