An evidence-based treatment approach is well supported in the literature for patients with osteoarthritis (OA). Physical therapists (PT) have clinical practice guidelines that clearly direct the care we provide our patients. There is strong evidence to support supervised exercise by both the American Physical Therapy Association and the American Academy of Orthopaedic Surgeons. The 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee was updated and once again concluded that exercise interventions were strongly recommended, with better outcomes when the exercise is supervised.

Less clear is what type and how much exercise is right for everyone. This is when the skills and contributions of an effective PT can help. A PT, for example, will look at the patient holistically, with an eye toward each patient’s unique history with health and well-being, social and cultural influences, functional objectives, and barriers to treatment. What does the patient want to achieve, and what are their limiting beliefs? Can the PT establish enough trust with the patient to facilitate shared decision making? Critically, at the point of initial evaluation, can the PT gather enough data from a diverse set of inputs to craft a treatment plan most likely to overcome the patient’s real and perceived barriers, and meet their health and well-being goals? As a professional who understands the importance of these variables in driving successful outcomes for patients with OA, the PT is an invaluable piece of the OA patient’s healthcare team.

Evidence always guides a PT’s evaluation and treatment, and evidence collection begins when the patient walks through the door. First and foremost, we view the patient as a person, a unique individual with a diverse set of personal beliefs and cultural influences, and a unique history with wellness and exercise. These individuals have varying degrees of trust in the healthcare system and different ideas about movement and exercise. For example, the importance of a healthy, active lifestyle seems obvious to a PT. But when a patient comes to physical therapy with years of chronic joint pain, the idea that physical activity exacerbates symptoms is real. Changing these long-held beliefs regarding movement and exercise can be challenging and must factor into the treatment plan. Finally, any complete understanding of the patient must include functional goals. What does this person enjoy in their life? What does this person have difficulty doing? While key to driving meaningful, patient-focused care, and keeping the patient motivated, this also keeps the PT engaged and focused.

Success in treating patients with OA requires trust between the PT and patient. I have an open dialogue with my patients. I want them to understand clearly that their success in physical therapy depends entirely on the strength of our partnership. There is no magic here. There isn’t a fixed intensity of physical activity or specific exercises that work for every patient. Rather, the treatment is highly variable, customized to each patient, based on the input and feedback provided by PT and patient. It may take a couple of visits, with modifications along the way, to figure out what will work best for my patients in achieving their goals. This environment of shared decision making between patient and PT is particularly valuable in building a trusting relationship with your patient. Trust begins with setting clear and realistic expectations. During our physical therapy education, we learn that regular exercise is important for relieving pain and improving function. There is clear evidence supporting this, but the way that is implemented is more nuanced. Strengthening is so vital to improvement in this patient population, but there can be a fine line of pushing a little too hard and temporarily creating an increase in that joint pain and stiffness. Experience helps, but also setting expectations with our patients very clearly on day one is the most beneficial. Positive outcomes come from an individualized connection to sustained physical activity and a trusting partnership between patient and PT.

We are aware that patients with OA have low compliance to physical activity recommendations both during treatment and after discharge, which speaks to the chronicity of the disease. We are always asking ourselves, what can we do to improve adherence? The persistent nature of OA can result in the patient feeling powerless over the outcome. And beginning any lifestyle change requires support from family, friends, and people in health care. If we identify barriers these patients may have to these changes and introduce solutions that are likely to work, specifically for that patient, we are more likely to see a better outcome. Cultural factors can play a role. For example, for some of my patients, a more traditional strength-training regimen might not resonate with them. Access to weights in a gym could be limited. Further, some of my patients who practice tai chi might prefer incorporating dynamic fluid movements into their treatment plan. Helping the patient align physical activities with social and cultural enablers will increase the likelihood of adherence. These factors, coupled with a positive mindset, and the support and motivation of the patient’s immediate network, can instill confidence in their healthcare providers and lead to positive outcomes. A critical part of the PT’s job is to help their patient realize that pain relief and improvement in quality of life is possible and can be life-changing, provided they remain engaged in the partnership we’ve created.

Understanding the patient holistically, fostering a safe and trusting partnership, and assessing barriers to compliance are critical in establishing a treatment plan, which first takes shape at the initial evaluation. As a PT, our expertise lies in movement assessment. From the moment a patient walks in the door, the assessment begins. Our initial examination includes how the person walks from the waiting room to the exam area, how they negotiate obstacles, take off their coat, and move from standing to sitting in a chair. Our primary goal is to help the patient improve quality of life through education and individualized exercise. This could not be truer than for our patients with OA. Along with observation of how a patient moves, where they move, and where they don’t move, we compile objective measurements during our initial assessment that allow us to track a patient’s progress. Validated outcome measures and performance tests are two approaches that assess a patient’s baseline status, as well as their progress during treatment. The outcome measures help assess a patient’s activity limitations as well as participation restrictions, which are different for every patient we meet. These data are invaluable for the PT and the patient alike. They provide the basis for treatment and act as an incentive for the patient to monitor progress in a very visible, tangible way.

The initial evaluation is also when the PT identifies impairments in joint range of motion, muscle strength, joint mobility, flexibility, pain, gait, and balance dysfunction. In many cases, part of this initial conversation must broach the subject of weight management, specifically with lower extremity OA. Evidence shows that being overweight or obese is a significant risk factor in hip and knee OA. If we are not discussing this with our patients from day one, we are doing them a great disservice. Physical therapy and integrating activity are only part of the solution. The patient’s primary care physician, dietician, and other members of the healthcare team play vital roles in the success of our patients. Keeping clear, concise lines of communication among different disciplines open is vital to success.

All these inputs allow the PT to develop a highly customized treatment program. On the surface, this program consists of strengthening exercises, flexibility/stretching, endurance exercise, manual therapy, balance training, and training with an assistive device, if appropriate. Beneath the surface, the treatment is tailored to match a patient’s interests and ultimate goals for physical therapy. For example, the exercise programs for my patient who is a long-distance runner will look vastly different than the program for my patient who needs to walk no further than to the end of their driveway to get the mail. I also consider their access to resources post discharge, and what physical activities are interesting to them. For the long-term benefits of physical therapy to accrue, there must be permanent, sustainable changes in physical activity.

After a patient starts physical therapy, regular physical activity can have a variety of benefits that quickly become apparent. Sometimes, the most unexpected is an early reduction in pain and stiffness. The benefits aren’t just restricted to the musculoskeletal system. Patients often experience an improvement in their mood, a boost in energy, and a better night’s sleep. Patients can experience more long-term benefits, including helping with weight management, a reduction in blood pressure, and reduction in risk of falls through improved balance and coordination.

Exercise is commonly recommended in treatment guidelines as a core treatment of OA. The benefits of referring someone to physical therapy is that the PT can develop a tailored exercise program that is paired with patient education to collectively reduce barriers to exercise adherence, and make nuanced decisions about intensity and dosage of the exercises, while focusing on the functional goals important to the patient. Although OA and its symptoms can look the same to patients and providers, we know that its treatment and outcomes can be highly variable. While adhering to evidence-based treatment, the many diverse objectives, histories, influences, and backgrounds in patients with OA require the PT to be incredibly collaborative and flexible in practice, to best serve the patient.