MANAGEMENT OF OSTEOARTHRITISNon-pharmacological managementEducation and behavioural interventionEducation of patients with OA can reduce their pain and improve their quality of life.The aim is to provide patients with an understanding of the disease process, its prognosis and the rationale and implications of managing their condition. Patients can be educated during the consultation with a doctor, through consumer groups or by being provided with written material.
Weight LossObesity is a risk factor for the development of OA, and is associated with radiological progression of the disease, and disability.When people walk, three to six times their body weight is transferred across the knee joint; any excess weight should be multiplied by this factor to estimate the excess force across the knee joint of overweight people.Small studies of overweight patients with knee OA have shown that modest weight loss (< 5 kg) has significant short-term and long-term reduction in symptoms of OA.
In managing OA, weight reduction should be a key goal. Exercise plays a role, but pain and disability can make it difficult for patients to exercise sufficiently to lose weight. Weight loss can be achieved with regular sessions with a dietitian who can provide instruction on reducing caloric intake and the use of food diaries, and cognitive-behavioural modification to change dietary habits.
ExerciseThe aim of exercise is to reduce pain and disability by strengthening muscle, improving joint stability, increasing the range of movement and improving aerobic fitness. Other, theoretical benefits include better self-esteem, weight reduction and improved general health.
Systematic reviews of short-term exercise programs show a small to moderate reduction of pain and disability, with similar benefits seen regardless of the type of exercise.Many such programs have involved intensive supervision and sophisticated equipment, with their sustainability over time unknown. A simple, largely unsupervised, home-based exercise program has been shown to reduce knee pain and disability, with its effects sustained over two years.Although hydrotherapy is widely used, no trials have shown any advantage over land-based exercise. Anecdotally, patients enjoy hydrotherapy and it may be a gentle start in encouraging exercise.
Osteoarthritis at different sites requires different approaches. Range-of-motion exercises may exacerbate pain in OA of the hip, and extension exercises can worsen the pain in patellofemoral OA. Thus, an individual exercise program should be formulated with the patient in consultation with a doctor, physiotherapist or qualified fitness instructor.
Mechanical aidsAlthough there is no evidence available from well-designed trials to support the efficacy of walking sticks in OA, they are widely recommended.Patients should be encouraged to wear shock-absorbing footwear with good mediolateral support, adequate arch support and calcaneal cushion. Short-term studies have shown biomechanical aids are effective in reducing OA-related pain. Lateral heel wedges may reduce pain related to OA of the medial tibiofemoral compartment,and applying adhesive tape to the patella can provide relief in patellofemoral OA.In patients with significant varus deformity, use of a tube-like knee support made of neoprene or an unloader brace both reduced pain over 6 months, with the brace being slightly more effective.Both may be uncomfortable to wear and the brace is expensive. Physiotherapy and occupational therapy assessment are recommended if there is functional limitation secondary to OA.
Pharmacological managementPharmacological management should be considered an adjunct to non-pharmacological measures. Drug therapy should be individualised after a careful assessment of symptom severity, comorbid conditions, concomitant therapy, side effects, cost of therapy and patient preferences.
Systemic drugsParacetamolIt is widely accepted that paracetamol is the oral analgesic of first choice and, if successful, should be taken long term.Although some patients prefer non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol should be used as initial therapy based on relative cost and safety. It should be taken in divided doses, at regular intervals, with the total daily dose not exceeding 4 g. Although it is one of the safest analgesics, paracetamol can be associated with clinically important adverse events. Paracetamol may prolong the half-life of warfarin, so patients taking warfarin must have their INR (international normalised ratio) monitored closely and their warfarin dose adjusted if necessary.Paracetamol should be used with caution in patients who have liver disease and those with a history of excessive alcohol consumption.
NSAIDs and cyclo-oxygenase-2-specific inhibitorsNSAIDs should be considered only for patients who do not obtain adequate pain relief with paracetamol. Clinicians now have a choice between conventional NSAIDs and cyclo-oxygenase-2-specific (COX-2) inhibitors. COX-2 inhibitors have similar analgesic effects to those of non-selective NSAIDs, with a gastrointestinal (GI) side-effect profile and incidence of endoscopic ulceration similar to placebo.Both NSAIDs and COX-2 inhibitors may cause acute deterioration in renal function, fluid retention and hypertension. The newer COX-2 inhibitors are considerably more expensive than NSAIDs, and uncertainty remains about potential increased risk of cardiovascular events. Cardiovascular risk factors should be considered and patients should be counselled before prescribing rofecoxib (Box 4).
The choice between NSAIDs and COX-2 inhibitors should be made after carefully assessing the risk of serious upper-GI complications and discussing with patients the risk of serious thrombotic cardiovascular events. Patients with no risk factors should use conventional NSAIDs, commencing at a low dose, with dose titration against effect. NSAIDs should be used on an as-required basis, although this often means continuous use. All NSAIDs have similar efficacy, so those with the lowest risk profile for upper-GI haemorrhage (ibuprofen and diclofenac) are recommended. COX-2 inhibitors are recommended for patients with any GI risk factors.Rofecoxib should be avoided in patients with known risk factors for cardiovascular disease. All patients prescribed NSAIDs and COX-2 inhibitors should be counselled about the symptoms of upper-GI haemorrhage and monitored for new or severe upper-GI symptoms. NSAIDs should never be used in combination, except with low-dose aspirin for cardioprotection.
For patients with any risk factors for deterioration in renal function, NSAIDs and COX-2 inhibitors should only be prescribed after very careful consideration of all other options. Plasma sodium, potassium and creatinine levels, blood pressure and the presence of oedema should be checked at baseline and regular intervals.
Glucosamine and chondroitinGlucosamine sulfate (GS) and chondroitin sulfate (CS) are derivatives of glycosaminoglycans found in articular cartilage, and are available without prescription from pharmacies and supermarkets.Oral GS is able to reduce pain from
20%-25% in patients with mild to moderate primary knee OA.GS is contraindicated in seafood allergy, but is otherwise well tolerated and causes no major side effects. GS should be used at a dose of 1500 mg per day as a divided dose for at least 3 months to determine whether it is therapeutic in any given patient. Topical application of GS and CS may be effective in reducing pain from knee OA.
OpioidsThe combination of codeine and paracetamol provides better analgesia than paracetamol alone. However, nausea, vomiting, dizziness and constipation lead to discontinuation of this combination in up to a third of patients.Some patients with intractable pain, who are unsuitable for arthroplasty, may require stronger opiate analgesia. Tramadol is a centrally acting synthetic opioid which inhibits the reuptake of serotonin and noradrenaline. It is generally well tolerated, but is contraindicated in seizure disorders, as it lowers the seizure threshold, and in combination with selective serotonin reuptake inhibitors because of the risk of serotoninergic syndrome.
Topical analgesiaTopical treatment is appropriate for patients as an adjunct to simple analgesia, monotherapy for a single symptomatic joint, or for patients who cannot tolerate systemic therapy. Topical capsaicin has a modest analgesic effect.A local burning sensation is common, but decreases with continued use. Patients must avoid inadvertently transferring the capsaicin to eyes or mucous membranes.
For optimal results, management of OA requires multiple therapies and an individualised approach. Patients need to be involved in formulating and executing the management plan. As the disease progresses, or as comorbid conditions develop, management may need to be revised. The doctor’s role is to coordinate non-pharmacological approaches, supervise pharmacological management with the aim of minimising toxicity, and empower patients to manage their chronic condition.
PREVENTION OF OSTEOARTHRITISWeight control. Maintaining a healthy weight may be the single most important thing you can do to prevent osteoarthritis.Being overweight puts extra strain on the joints, particularly the large weight-bearing joints such as the knees, the hips, and the balls of the feet. It is estimated that every 1lb of body weight means at least 3lb of stress at the knee joint, and even more at the hip joint. That would mean that losing just 5lb would take at least 15lb of stress off your knees. Extra weight may also alter the normal structure of the joint and increase the risk for osteoarthritis. Maintain a healthy weight to prevent or reduce joint damage and lower the stress on osteoarthritic joints.
Injury prevention. Protect your joints from serious injury or repeated minor injuries to decrease your risk of damaging cartilage. Repeated minor injuries include those from job-related activities such as frequent or constant kneeling, squatting, or other postures that place stress on the knee joint.
Exercise. Exercise can help reduce joint pain and stiffness. Light- to moderate-intensity physical activity may prevent a decline in, and may even restore, health and function.But some people with osteoarthritis may be reluctant to exercise because of joint pain after activity. You can take various steps to help relieve pain, such as heat and cold therapy or taking pain relievers, which may make it easier for you to exercise and stay active. Choose partial– or non–weight-bearing exercise, such as bicycling, swimming, or water exercise. You can also try light weight-lifting exercises, with supervision.
Research shows that even modest weight loss combined with exercise is more effective in decreasing pain and restoring function than either weight loss or exercise alone.
Young adults who have significant knee injuries have an increased risk of future osteoarthritis. Prevention of joint injuries during youth depends in good part on the use of proper sports equipment and on playing under safe playing conditions. A young person who has a serious knee injury can limit further damage by using a brace to stabilize the knee joint and by changing the way he or she does high-impact exercise.
Heat and cold therapy for osteoarthritis
For moderate to severe pain from osteoarthritis, try applying heat and cold to the affected joints as appropriate. Experiment with these heat and cold techniques until you find what helps you most.
-Apply heat 2 or 3 times a day for 20 to 30 minutes, using a heating pad, hot shower, or hot pack. Heat seems to be effective for pain and stiffness related to inactivity of a joint.
-Try putting cold packs on a painful joint for 10 to 20 minutes. Do not apply a cold pack directly to bare skin. Put a thin towel or pillowcase between the ice and your skin.
-Try ice massage. A small study showed that ice massage for 20 minutes, 5 days per week, improved range of motion and function, although its effect on pain was less clear.
-Try alternating between heat and cold.
-After a heat or cold treatment, try some gentle massage for relaxation and pain relief.
-Paraffin wax is a form of moist heat that may help if you have pain and stiffness in your hands or feet. It is especially useful before exercise. Your physical therapist can teach you to use paraffin at home.
