Nonpharmacologic Therapy

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Nondrug therapy consists of a three-pronged approach of education, lifestyle modification, and physical therapy. Educational programs include a set of systematic educational activities designed to improve health behaviors and health status, thereby slowing OA progression. The goal is to increase patient knowledge and self-confidence in adjusting daily activities in the face of evolving symptoms. Effective programs produce positive behavioral changes, decreased pain and disability, and improved functioning. In addition to physical outcomes, psychological outcomes such as depression, self-efficacy, and life satisfaction are positively influenced. Patients can be referred to the Arthritis Foundation (www.arthritis.org) for educational materials and information on support groups.

^^ Lifestyle modification should be employed in all patients at risk for OA and in those with established disease. Aerobic exercise and strength-training programs improve functional capacity in older adults with OA. Stretching and strengthening exercises should target affected and vulnerable joints. Isometric exercises performed three to four times weekly improve physicalfunctioning and decrease disability, pain, and analgesic use. Some patients have the misconception that increased activity will exacerbate joint symptoms, but controlled clinical trials have invalidated this belief.10 The American Geriatrics Society issued guidelines on the implementation of exercise in OA patients.11 In general, it is advisable to recommend performing low-impact exercise routinely.

Obesity's association with both the onset and progression of OA make weight loss a pivotal treatment strategy in overweight and obese patients. Women who lose an average of 5 kg (11 lb) lower their risk of knee OA by more than 50%. Symptomatic relief from knee OA and improved quality of life occur in people with knee OA who reduce their body weight. Weight loss should be pursued through dietary modification and increased physical activity (see Chap. 102). It is important to consider the patient's physical capabilities when implementing an exercise program.

^^ Application of heat or cold treatments to involvedjoints improves range of motion, reduces pain, and decreases muscle spasms. Practical applications of heat therapy include warm baths or warm water soaks. Heating pads should be used with caution, especially in the elderly, and patients must be warned of the potential for burns if used inappropriately.

Referral to a physical or occupational therapist may be helpful, particularly in patients with functional disabilities. Physical therapy is tailored to the patient and may include assessment of muscle strength, joint stability, and mobility; use of heat (especially prior to episodes of increased physical activity); structured exercise regimens; and implementation of assistive devices, such as canes, crutches, and walkers. The occupational therapist ensures optimal joint protection and function, energy conservation, and use of splints and other assistive devices.

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