There are a lot of opinions and misconceptions surrounding the topic of arthritis, particularly when it comes to the topic of where arthritic pain comes from.

To unpack this, it’s first worth discussing what arthritis is NOT.

Arthritis is NOT a wear-and-tear disease caused by increased load, leading to cartilage loss. This is a common misunderstanding and exacerbates the idea that exercise and activity are a bad thing, speeding up the process of additional wear and tear- however, evidence actually tells us that this is a whole joint problem.

Pain may arise from many sources, and it is, in fact, the LACK of physical activity that can contribute to additional pain!

Exercise assists regeneration of the cartilage, as movement is required to distribute synovial fluid (fluid within the joints which cushions the ends of the bones and reduces friction during movement) to the joint, since cartilage has no direct blood supply.

Symptoms of arthritis usually include pain and stiffness during movements- for example, with knee or hip arthritis, activities like walking, running, climbing stairs, or rising from a chair, can be painful.

Arthritis is extremely common, with 1 in 11 Australian’s (2.1 million people) affected, and 30% of people aged 50 and above reporting hip and or knee pain (1).

How do we Diagnose it?

Once again contrary to popular belief, x-ray is not recommended, despite being commonly offered by many practitioners to diagnose the problem. Diagnosis is made clinically, with the behavior of pain and symptoms, combined with risk factors and the clinical presentation, being the keys.

Features commonly seen are morning pain or stiffness that eases up with movement, reduced joint range of motion, and pain on activity.

It is common that pain starts over time without a mechanism of injury. For example, you start noticing pain whilst cycling or running, but there was no obvious incident that could have caused this discomfort.

It is more common in people that are older, and those with a history of significant injury in their younger years (for example, having an ACL tear in their knee in their 20’’s and developing knee pain later in life without a new incident or injury).

Common Myths About Osteoarthritis

Sadly, myths around arthritis are not only common, but often held by both patients and health practitioners alike.

Some of those most common myths include:

· The degree of osteoarthritis seen on imaging can predict pain and disability

· Pain equates to physical damage

· Exercise is dangerous and will wear the joint out further

· Rest is helpful

What we know through evidence heavily contradicts this:

· Scans often don’t accurately relate to pain and disability

· Pain does not equal damage, and is influenced by many factors

· Exercise is safe, and helps pain symptoms

· Rest and avoidance of pain makes pain and disability worsen over time

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So, if it is not an indication of damage, or a reflection of degeneration shown in imaging, what factors ARE influencing pain in osteoarthritis?

There are many factors that influence pain, and surprisingly, this is a good thing, as many of these factors can be modified.

Fear about pain, and loss of confidence in your body as a result, are common factors that affect the level of pain. With improved understanding of their pain, and being able to build their confidence and strength with that knowledge to push into low levels of pain safely, many people will begin to improve. Their pain reduces, the amount of exercise increases, and daily activities that used to hurt often improve. And yet, despite this obvious physical improvement, their imaging would look unchanged.

Other factors that can contribute to pain include stress, fatigue, low sleep, beliefs based on imaging findings, and more.

Building strength is a great way to not only restore tissue capacity, but confidence in your body. And this often has a substantial influence in decreasing pain.

What does evidence say is the best way to manage osteoarthritis?

The evidence is quite clear across guidelines in multiple countries that exercise, education about the condition and pain, and weight loss where appropriate, are the keys and should be recommended to all people with hip and knee osteoarthritis.

This is regardless of the level of pain, disability, or how advanced the joint degeneration appears on imaging!

Sadly, again, evidence also says that this is clearly not the information and treatment that people out there are receiving.

There are many people being offered injections, and surgery, often without even trying these universally recommended strategies first!

What is the GLA:D program for osteoarthritis?

GLA:D (‘Good Life with osteoArthritis in Denmark) is an education and exercise program developed by researchers in Denmark for people with hip or knee osteoarthritis. They noted that despite clear evidence that exercise, appropriate advice, and weight loss all offer effective relief to arthritic pain, most people were not getting offered this and were instead being given more invasive pathways.

The program was brought to Australia in 2016 and has been shown to have well documented excellent outcomes.

The structure of the GLA:D program is as follows:

· Group exercise for 60 mins twice a week, over a 6-week period

· Two 60 min education sessions, where you learn about osteoarthritis, pain, and your pathway to recovery.

· Questionnaires are given, as well as some objective testing at the start and end of the program, so you can measure personal changes such as pain, function, quality of life, and medication use.

I recently took some ladies through the program with knee arthritis, and they had great results, consistent with what is seen around the world (2).

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What about options for my osteoarthritis other than the GLA:D program?

The GLA:D program can be great for several reasons including:

· Support during exercise to help with confidence, exercise selection, and managing pain safely, as well as being an overall supportive team environment

· Knowing you have your exercise class locked in can be great for some people in helping them stay accountable and commit to the full program.

· With your physiotherapist, you can modify the program and ask questions based on your specific needs, and the pain or fear you may have.

For others, particularly who are highly disciplined and accountable, they may need less support to commit to the structure of the GLA:D program.

In these instances, a tailored exercise program that they can do on their own can be a great solution. This can be done at home, or in a gym, based on what works with their lifestyle.

Again, education from their physiotherapist can be a key component, not just to progress exercise suitably, but to understand pain response and build confidence and load in an appropriate way.

What about surgery?

Surgery is a good option for some people, particularly if they have tried a comprehensive education and exercise approach first.

Many people who undergo GLA:D end up cancelling or delaying joint replacements, as their pain and function improves considerably. Surgery should be reserved for the very few that need it, and not be offered as a throw-away solution as it often is.

It is also worth noting that with a hip replacement, around 95% of people are happy with their outcome (3). In knee replacement, however, this figure is around 80% satisfaction, which sounds solid, but that is still 20% of people who have a replacement who are not satisfied with pain and function afterwards.

Additional Resources

Want more information about OA, or the GLA:D program??

Works Cited
1. Australian Institute of Health and Welfare. (2020, Augsut 25). Osteoarthritis. Retrieved from Australian Government: AIHW: aihw.gov.au/reports/arthritis-other-musculoskeletal-conditions/osteoarthritis/data
2. GLA:D Australia. (2017). International research publications. Retrieved from GLA:D Australia: https://gladaustralia.com.au/key-evidence-surrounding-glad/
3. GLA:D Australia. (2017). Infographics on Joint Health. Retrieved from GLA:D Australia: https://gladaustralia.com.au/joint-health-infographics/

Arthritis - A Comprehensive Guide to Pain Education, Management, and the GLA:D Program