What is the recommended management for a patient with bilateral hand pain, bilateral knee pain, and right hip pain, who also experiences anxiety and has a sedentary lifestyle due to anxiety related to exercising?

Management of Polyarticular Joint Pain with Comorbid Anxiety

For this 46-year-old patient with bilateral hand, knee, and right hip pain who avoids exercise due to anxiety, initiate a dual-track approach: start Tai Chi or yoga as the primary exercise intervention (which addresses both joint pain and anxiety simultaneously), combined with cognitive behavioral therapy (CBT) to directly target the anxiety barrier preventing exercise engagement. 1

Why Mind-Body Exercise is the Optimal Starting Point

Tai Chi is strongly recommended for patients with knee and/or hip osteoarthritis and offers unique advantages for this patient's specific situation. 1 The efficacy of Tai Chi reflects its holistic impact on strength, balance, fall prevention, depression, and self-efficacy—making it ideal for someone whose anxiety prevents traditional gym-based exercise. 1

• Tai Chi combines meditation with slow, gentle movements, deep breathing, and relaxation, which directly addresses both the physical joint symptoms and the psychological anxiety barrier. 1
• Sessions typically occur 3 times weekly and can be held in person or online, providing flexibility for someone with gym-related anxiety. 1
• Yoga is conditionally recommended for knee osteoarthritis and may serve as an alternative if Tai Chi is not accessible or acceptable to the patient. 1

Address the Anxiety Barrier Directly

Cognitive behavioral therapy (CBT) is conditionally recommended for patients with knee, hip, and/or hand osteoarthritis and is particularly relevant given this patient's anxiety-driven exercise avoidance. 1

• CBT has demonstrated improvement in pain, health-related quality of life, negative mood, fatigue, functional capacity, and disability in chronic pain conditions. 1
• Anxiety is highly prevalent among patients with joint pain (16.1% report clinical anxiety), and those with anxiety are significantly less likely to undertake general fitness exercises (OR 0.60,95% CI 0.52 to 0.70). 2
• Patients with osteoarthritis and comorbid anxiety experience more pain, have frequent hospital visits, take more medication, and report less optimal outcomes. 3

Self-Management Programs as Foundation

Self-efficacy and self-management programs are strongly recommended for patients with knee, hip, and/or hand osteoarthritis. 1

• These programs use a multidisciplinary group-based format combining skill-building (goal-setting, problem-solving, positive thinking), education about the disease, joint protection measures, and fitness and exercise goals. 1
• Sessions can be led by health educators, nurses, physical therapists, occupational therapists, physicians, or patient peers, and can be held in person or online. 1
• This approach is particularly valuable for building confidence in someone who currently avoids exercise due to anxiety. 1

Pharmacologic Management for Pain Control

Start with acetaminophen or topical NSAIDs as first-line agents for pain management, as these have lower systemic exposure and toxicity. 4

• Acetaminophen is recommended for pain relief with minimal systemic effects. 4
• Topical NSAIDs are recommended for non-low back musculoskeletal injuries and may be appropriate for hand pain. 5
• Avoid opioids in this population—patients with clinical anxiety are more likely to use opioids (OR 1.34,95% CI 1.18 to 1.52), which presents additional risk. 2

Assistive Devices and Orthoses

Hand orthoses are strongly recommended for first CMC joint osteoarthritis, and conditionally recommended for other hand joints. 1

• A variety of mechanical supports are available, including digital orthoses, ring splints, and rigid or neoprene orthoses. 1
• Kinesiotaping is conditionally recommended for knee and/or first CMC joint osteoarthritis and permits range of motion unlike rigid braces. 1
• Cane use is strongly recommended for patients with knee and/or hip osteoarthritis when disease is causing sufficient impact on ambulation, joint stability, or pain. 1

Weight Management if Applicable

If the patient is overweight or obese, weight loss is strongly recommended for patients with knee and/or hip osteoarthritis, with clinically important benefits continuing to increase with weight loss of 5-10%, 10-20%, and >20% of body weight. 1

• The efficacy of weight loss for osteoarthritis symptom management is enhanced by use of a concomitant exercise program. 1
• Even modest weight loss can significantly reduce joint loading during functional activities. 6

Critical Pitfalls to Avoid

Do not allow the patient to remain sedentary—complete exercise avoidance leads to deconditioning and further functional decline. 7, 6

• The key is modifying the type and setting of exercise rather than eliminating it entirely. 7, 6
• Case-finding to identify and treat anxiety is appropriate in this population, with caution about opioid prescribing and consideration of exercise as an intervention. 2
• Patients with anxiety and osteoarthritis are more likely to use walking aids and assistive devices, but less likely to exercise—this pattern must be actively reversed. 2

Practical Implementation Algorithm

1. Refer to Tai Chi program (in-person or online) starting 3 times weekly 1
2. Refer to CBT to address anxiety and pain catastrophizing 1
3. Enroll in self-management program for skill-building and disease education 1
4. Prescribe acetaminophen for pain control as needed 4
5. Fit hand orthoses for bilateral hand pain 1
6. Consider kinesiotaping for knees 1
7. Provide cane if ambulation is significantly affected 1
8. Address weight loss if BMI >25 1

This approach directly addresses both the joint pathology and the psychological barrier preventing effective self-management, which is essential since psychological distress is common among individuals seeking comprehensive care for hip or knee osteoarthritis, and predominant biomedical interventions alone may be inadequate to fully meet care-related needs. 8