How does the natural progression of osteoarthritis influence the management of osteoarthritic flares?

Case Example:

Over the last year, on several occasions, a patient has sought assistance for recurring flaring neck pain. Radiographs show moderate osteoarthritic (OA) changes in the cervical spine. A history of mild to moderate scoliosis of the spine has existed since childhood.

Over the years, the neck pain has alternated from long periods of no pain to no dysfunction with periodic flares of intense left-side neck pain. During the flare, the pain disturbs sleep, interferes with work, and interrupts her regular exercise program. The symptoms are better if she lies down. She reports that the frequency of the periodic flares of intense neck pain is becoming more frequent, from 1 to 2 times a year to 4 to 5 times a year.

When the flares occur, she reaches out to me requesting manual therapy, joint mobilization, and assistance in getting pain relief for the flare of neck pain.

She expresses frustration with repeated questions.

Why do these flares happen?

What am I doing wrong?

How can I prevent the flares from happening?

I have tried to answer the questions by saying that:

• Rapid weather changes can trigger a flare.
• Pay more attention to your posture when sitting. Use a lift under the right buttock when sitting for prolonged periods of time.
• Don’t fall asleep in a soft chair watching TV late at night with your neck in an awkward position.
• Do flexibility and strengthening neck exercises on a consistent basis.
• Keep a diary taking notes of what happens in the 48 to 72 hours before the flare to identify triggers.

Despite her compliance with the above recommendations the flares of intense neck pain continue to recur.

What are alternative explanations or interventions to explain and to manage recurring flares of osteoarthritic neck pain?

The natural course of the osteoarthritic syndrome is not well understood. Osteoarthritic flare is an acute condition on a chronic condition.

MJ Thomas and colleagues propose a theory of the natural history of symptomatic OA syndrome. He suggests periods of symptom-free comfort are punctuated by intermittent benign flare-up episodes. The flare-ups may progress in frequency, intensity, and duration over time. The benign mild intermittent pain may progress to the constant pain. However, variability in individual experience is significant. Some individuals may not see a noticeable increase in flare frequency. Some individuals’ flares cease to recur.

Most of the research related to flares of OA has been done on the knee. Until more data becomes available the supposition is there is a commonality across OA of different joints neck, back, shoulder, thumb, hip, and knee.

What do we know about osteoarthritic flares?

• Osteoarthritic flares are a natural occurrence
• 70% of OA flares are without warning.
• Flares are unpredictable in terms of frequency, intensity, and duration.
• Flares last 3 to 8
• The average number of 4 flares per year
• Flares are less common in older individuals.
• The relationship between flare triggers and duration is unknown and highly variable.
• Flares are associated with activity-related exposure.

What are the potential proximal triggers of an osteoarthritic flare?

• Medication changes
• Sudden change or unaccustomed activity/exercise
• Being in the same position for prolonged periods of time, particularly sitting or standing.
• Weather changes – a rapid change in barometric pressure that occurs when a high-pressure weather system quickly changes to a low-pressure weather system or vis versa.

• Infection or stress to auto-immune system – bacterial infection, viral infection, vaccine injections
• Changes in emotional psychological stresses
• Other unique individual triggers.

Back to case example:

Returning to the frustrated patient with increasing frequency of flares of OA neck pain requesting manual therapy and assistance in getting pain relief for the flare of acute neck pain. Is manual therapy joint mobilization appropriate during acute episodes of neck pain?

According to the 2017 guidelines of the Academy of Orthopedic Physical Therapy

for acute neck pain with mobility deficits, clinicians may provide cervical manipulation and/or mobilization. The guidelines cite only two poorly designed studies supportive of the use of manual therapy for acute neck pain. The guidelines conclude that there is extraordinarily little evidence supporting it and the evidence is weak.

If manual therapy is used during a flare of OA skeptical and frequent reassessments can determine if the intervention provides:

• Temporary symptoms reduction
• No effect on symptoms
• Worsens symptoms.

Is there a better use of time and resources than manual therapy?

Can watchful waiting or tincture of time during an acute flare of OA be an appropriate intervention? Watchful waiting or active surveillance has been recommended in other medical conditions. Recognizing a flare will get better given time. If the flare does not get better than reach out to healthcare professionals.

When and if the above patient experiences another flare of OA neck pain below is an outline of care.

What can be included in a personalized approach to the management of acute osteoarthritic flares?

• Use symptomatic treatment to decrease pain – heat/cold, medication, external supports/assistive devices.
• Keep a diary to collect data points.
  • Identify potential triggers that occurred 24 to 48 hours before the flare.
  • How long does the flare last?
  • How frequent flares are occurring.
• Strive to mitigate triggers.
• Use a self-administered movement-evoked pain measurement to adjust activity/exercise, and interventions, particularly during the periodic flares.
• Decrease activity/exercise during the flare. – switch to “rest & protect” mode for a while
• During the flare “watchful waiting” or tincture of time may be the best treatment.

• Resumes an active self-management program for OA after the flare subsides.

The above discussion is related to osteoarthritic flares, but the concepts are likely applicable to rheumatic arthritic flares.

The information on this website is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment. You are encouraged to perform additional research regarding any information contained available through this website with other sources and consult with your physician.