What To Do About Osteoarthritis

Health and Chronic Disease

The longstanding definition of health from the World Health Organization (WHO) is “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” and goes on to state that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” (WHO, 2014, p.1). There has been much debate over this long-held definition, with one of the largest deficiencies identified as being the limitations of using the word “complete”. Complete health is nearly an impossible goal for many to reach, and this is especially true for those who live with a chronic disease. Instead of seeing health as the absences of disease, we should think of health as a multidimensional system that includes physical, mental, and social health (Huber, 2011). Seeing health as a state of balance between the person and social and physical environments allows for those living with disease or impairment to still be considered as healthy or have an optimal level of health (Sartorius, 2006).

What is Arthritis?

Arthritis is a chronic disease that affects approximately 4.8 million Canadians over the age of 15 (Statistics Canada, 2014). The term arthritis can describe over 100 diseases that are characterized by inflammation of the joint or other areas of the body, but most commonly affects the hip, knee, spine, or other weight bearing joints. Arthritis can also be found in the fingers and other non-weight-bearing joints (Arthritis Society, n.d.). Osteoarthritis (OA) is the most common form of arthritis and affects approximately 4.4 million Canadians, more than all other forms combined (Bombardier, Hawker, & Mosher, 2011). There is no cure for osteoarthritis; it is a progressive joint disease that causes irreversible damage to cartilage and bone (Robinson, 2011). Osteoarthritis can result in long-term disability, poor quality of life, and is associated with mobility limitations, dependency in activities of daily living, and increased likelihood of medication use (Bombardier et.al, 2011).

Figure 1: Arthritis diagnosis by age group and sex from Statistics Canada, 2008.

Arthritis affects a substantial number of Canadians in their prime working years, and as a result this can have a significant impact on the Canadian labour force (Bombardier et.al, 2011). In 2008 Statistic Canada released rates of arthritis by age group and in the 45-64 age group 17.2% of males and 24.8% of females (1.9 million people in total) reported an arthritis diagnosis (figure 1). It is estimated that the incidence rate for osteoarthritis will continue to rise over the next 30 years and by 2040 may affect 10.4 million Canadians (Bombardier et.al., 2011). Arthritis is the most common cause of disability in Canada resulting in both poor quality of life and workplace limitations; it is also costly in both personal and economic terms. It is estimated that 40% have moderately severe hip and/or knee OA, with an additional 5% with severe OA (Bombardier et.al, 2011). Among the Canadian adult population living with osteoarthritis one in one hundred are living with moderate to severe pain, which is limiting their activities (Bombardier et.al, 2011).

Risk factors for developing arthritis include unmodifiable risks such as age, sex, and genetics, and modifiable risk factors such as diet, weight, physical inactivity, injury, smoking, occupation, and infection (Arthritis Society, n.d.). Osteoarthritis is mostly caused by wear-and-tear of the joints, which accumulates as people age (Robinson, 2017). There are many treatment options that can reduce the progression of osteoarthritis and provide symptom management. If all other options no longer relieve pain and loss of function becomes severe, surgical intervention is usually performed (Arthritis Society, n.d.).

Arthritis symptoms can often be relieved or significantly improved through multiple treatment options. These options include medication, physical activity, occupational therapy, physiotherapy, weight management, and improved lifestyle measures (Arthritis Society, n.d.). Weight management is a key intervention; unloading joints is a priority when managing symptoms of osteoarthritis (Robinson, 2011). The simplest way to manage this is by losing weight. For each pound lost three pounds of force is lost off each hip and knee joint (Robinson, 2011).

The Social Ecological Model.

Figure 2: Social Ecological Model of Health from the Centre for Disease Control.

One approach to assessing the impact of chronic disease is to use a multilevel model of health. The social ecological model (figure 2) highlights the relationship between the multiple factors influencing health outcomes for patients, and the dynamic relationship between all levels (Stokols, 1996). The levels begin with the individual at the core and can include behaviour, knowledge, and attitude (Stokols, 1996). Expanding from the core level is the interpersonal level which can include support systems such as family and friends, as well as cultural dimensions and social cohesion. The community level includes support groups, resource centers within the community. The organizational level includes access to services such as physiotherapy and occupational therapy, consult to surgical services, and occupation or working conditions. The policy level is the highest and includes policies and funding allocations (Center for Disease Control, n.d.).

When looking at chronic disease through a multilevel model it is important to be aware of the determinants of health as they can relate to the chronic disease, and also to the levels of influence within the social model. The determinants of health as described by Health Canada (2018) include:

1. Income and social status

2. Employment and working conditions

3. Education and literacy

4. Childhood experiences

5. Physical environments

6. Social supports and coping skills

7. Healthy behaviours

8. Access to health services

9. Biology and genetic endowment

There are multiple determinants that affect the population living with osteoarthritis, but the primary focus are employment and working conditions, social supports and coping skills, healthy behaviours, and access to health services. All of these determinants can be linked to risk factors for the development and increasing severity of osteoarthritis.

The determinants of health within the first level of the individual, and expanding to the interpersonal level, include social supports and coping skills, and healthy behaviours. The risk factors for osteoarthritis related to this level include weight management, physical activity, diet, and healthy lifestyle. Weight management is a priority for symptom management; for each pound lost three pounds of force is lost off each hip and knee joints (Robinson, 2011).

The determinant of employment and working conditions falls within the community and organizational levels. One’s occupation can contribute to accelerating the breakdown of joint tissues and bone, for example heavy machine operators and construction workers are exposed more frequently to repeated stress on weight bearing joints (Arthritis Society, n.d.). Arthritis is the most common cause of disability in Canada, which can result in both poor quality of life and workplace limitations (Bombardier et.al, 2011).

Access to health services falls within all levels of the social ecological model. Physical access may be an issue for patients with mobility issues, as is common for patients with osteoarthritis (MacDonald, Sanmartin, Langlois, & Marshall, 2014). Resource availability can be an obstacle as some services such as physiotherapy and occupational therapy may not be fully funded; and medication can be costly and must be paid out of pocket until a minimum deductible is met (Manitoba Health, Seniors, and Active Living, 2018). In an effort to reduce surgical waitlists and provide patients with non-surgical options for symptom management the Winnipeg Regional Health Authority created The Hip and Knee Resource Center (Winnipeg Regional Health Authority, n.d.). This resource center provides information on the non-surgical treatment options for arthritis, and also helps patients prepare for a consult visit with the surgeon. There are also classes available for patients who are on a waitlist for surgery in order to optimize their health before surgery. All of these resources are available at no cost to the patient however patients must already be on a surgical waitlist to access this service (Winnipeg Regional Health Authority, n.d.).

At the policy level access to care focuses on surgical wait list management. Surgical intervention is usually performed only for severe symptoms of OA and once other treatment modalities have been exhausted. The current wait time for hip and knee replacement surgery in Manitoba varies between 14 and 55 weeks, with a median wait time for the province being 25 weeks (Manitoba Health, Seniors, and Active Living, 2018). The Canadian Institute for Health Information (CIHI) sets benchmarks wait times for hip and knee replacement surgery at 182 days,or 26 weeks (2018). Although some sites in Manitoba meet this benchmark, many do not. In fact, data from the last 5 years (2013-2017) shows that Manitoba is consistently failing to meet this mark. In 2017 only 53% of hip replacements and 43% of knee replacements were performed by the 26 week mark (Canadian Institute for Health Information, 2018). With enhanced access to total joint replacement surgery there is a projected savings over the next 30 years of more that 17 billion dollars to Canadian society due to saving in health care costs and wage-based productivity costs (Bombardier et.al., 2011).

Using the Multilevel Model.

In summary, using a multilevel model as a method of framing a chronic disease highlights the relationships between risk factors, determinants of health, and multilevel approaches to managing a chronic disease. Looking specifically at osteoarthritis, there are many resources available for those coping with this disease; however there is room for improvement. Many services are only available at some cost to patients, and most resources are only available once diagnosis is made. Policy level changes are needed in order to shift the focus from symptom management to symptom prevention.

References

Arthritis Society, What is Arthritis (n.d.). Retrieved June 22, 2018 from http://www.arthritis.ca/about-arthritis/what-is-arthritis.

Bombardier, C., Hawker, G., Mosher, D. (2011). The Impact of Arthritis in Canada: Today and Over the Next 30 Years. Arthritis Alliance of Canada: retrieved from http://www.ergoresearch.com/wp-content/uploads/2012/04/impact%20on%20arthrisis%20in%20canada_today%20and%20over%20the%20next%2030%20years.pdf.

Canadian Institute for Health Information, Benchmarks for Wait Times in Manitoba. Retrieved June 24, 2018 from http://waittimes.cihi.ca/MB#year.

Centers for Disease Control, Colorectal Cancer Control Program (CCRP). Retrieved June 15, 2018 from https://www.cdc.gov/cancer/crccp/sem.htm.

Health Canada (2018). Social determinants of health and health inequalities. Retrieved from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

MacDonald, K.V., Sanmartin, C., Langlois, K., Marshall, D. A. (2014). Symptom onset, diagnosis and management of osteoarthritis. Health Reports 25(9), 10-17.

Manitoba Health, Seniors and Active Living (2018). Summary of All Hip and Knee Surgeries. Retrieved from https://www.gov.mb.ca/health/waittime/surgical/all_hipknee.html.

Manitoba Health, Seniors and Active Living (2018). Pharmacare Deductible Estimator. Retrieved from http://www.gov.mb.ca/health/pharmacare/estimator.html.

Robinson, D. (2017). The new mid-life crisis: are you developing osteoarthritis? Winnipeg Regional Health Authority, retrieved form http://www.wrha.mb.ca/healthinfo/healthheadlines/2017/170317-osteoarthritis.php

Sartorius, N. (2006). The Paths of Medicine: The Meanings of Health and Its Promotion. Croatia Medical Journal (47), 662-24.

Statistics Canada (2014). Retrieved June 22, 2018 from https://www150.statcan.gc.ca/n1/pub/82-625-x/2015001/article/14178-eng.htm

Stokels, D. (1996). Translating Social Ecological Theory Into Guidelines for Community Health Promotion. American Journal of Health Promotion 10 (4), 282-298.

Summary of All Hip & Knee Surgeries, n.d. Manitoba Health, Seniors, and Active Living. Retrieved June 23, 2018 form https://www.gov.mb.ca/health/waittime/surgical/all_hipknee.html

Winnipeg Regional Health Authority, The Hip and Knee Resource Centre. Retrieved June 27, 2018 form http://www.wrha.mb.ca/prog/hipknee/index.php.