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Osteoarthritis of Weight Bearing Joints

Dr Chris Chin introduces a non-pharmacological technique to assist patients with osteoarthritis in their daily lives.

 Concurrent osteoarthritis of the back, hips and knees are common presentations in general practice, and share similar mechanisms. Apart from pain, stiffness and weakness contribute to significant mobility problems which can inhibit the person from performing weight bearing and cardiac exercises which then lead to weight gain, sarcopenia, osteoporosis and metabolic syndrome. As the musculature protects the joints from further degeneration, loss of muscle will cause a more rapid deterioration of their osteoarthritis and sets up a vicious cycle.

 Family members can sometimes see a rapid deconditioning in the patient who is suddenly unable to resume their usual dairy routines, hobbies, social outings and exercise, and subsequent inability to look after themselves.

 Dietary and exercise advice are important non-drug modalities we use to help our patients. For many years regular paracetamol was recommended, but recently it has been reduced to prn due to concerns of long term consequences. NSAIDS have the usual risk of gastrointestinal as well as cardiac side effects and opioids have the risk of tolerance, dependency, addiction and abuse. There is also the potentially fatal interaction with benzodiazepines.

Posture Breathing is an easy breathing technique that I teach my patients during the course of a consult and does not take up too much time.

 In my experience, patients complain of severe sharp exacerbations of pain with certain postures and movements and often this is when they are getting up from a chair or bed. They may also have difficulty getting off the toilet or getting out of a car. It is worse when the seat is low or soft. They may also feel weakness and have difficulty with stability while getting up. They may limp or feel pain for the first few steps after they get up. The mechanism for this phenomenon is that when they are leaning forward to get up, their ribs collide with their iliac crest impinging the lateral abdominal muscles causing pain and weakness to their core strength. The iliopsoas and gluteal muscles can also be impinged as they attach to the iliac crest. If the patient gives an involuntary gasp of pain it probably means that they are also impinge on the diaphragm which insert at the lower ribs.

 This impingement also occurs when patients go up or down stairs, bend over, lifting from a low level and certain exercises, including stretches like pulling their knees to their chest.

 Posture Breathing is an easy breathing technique that I teach my patients during the course of a consult and does not take up too much time. It will enable them to get off a chair with more strength and stability and less exacerbation of pain. This breathing technique works by activating the diaphragm and the abdominal muscles to increase intra-abdominal pressure to prevent costo-iliac impingement. Increasing intra-abdominal pressure when the patient is getting up has the added bonus of increasing venous return to the heart therefore reducing postural hypotension in our elderly patients and those on anti-hypertensives.

 The four steps of Posture Breathing are:
1. Take a deep breath in through the nose without making any noise.
2. Suck your abdomen in until you feel some muscle tightness while still holding your breath.
3. Keep holding your breath and abdomen in while getting out of the seat, using your arms to assist as much as possible.
4. Only breathe out slowly again through the nose after standing upright for a few seconds.

 You can teach the patient this at the end of the consult as they need to get out of your consulting room chair anyway. It’s a positive way to end a consult as you have given them a non-drug technique to improve their mobility, reduce pain exacerbations. Ask them to practice this technique at home each and every time they are getting out of a chair and give you some feedback on the usefulness of the technique on their next visit.

Dr Chris ChinDr Chris Chin M.B.,B.S.(W.A.), Medicine
When Chris started work as a GP, he developed back pain himself despite going to the gym three times a week and dragon boating on the weekends. After a year of analgesia, NSAIDs and physical therapy he was no better. One day he accidentally discovered how tender his ribs and his iliac crest were. He also found this phenomenon in almost all his patients with back and hip pain and then developed his theory of Hip Rib Impingement as the primary cause of back pain. In 2008 he self-published a self-help book “Be your Own Back Guru.”