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14 Articles in Volume 15, Issue #6
Antihistamine for G-CSF–Induced Bone Pain
Book Review: Advanced Headache Therapy
Brain Drain: Lymphatic Drainage System Discovered in the Brain
Case History of Chronic Migraine: Update 2015 Part 2
Disturbed Sleep: Causes and Treatments
Is Topical Ketamine Ready For Prime Time?
Letters to the Editor: Central Sensitization, Microglia Modulators, Supplements
New App Helps Interpret Urine Drug Test Results
Osteoarthritis Update: 2015
Pain Catastrophizing: What Clinicians Need to Know
PPM Editorial Board: Tips for Treating Osteoarthritis
Practical Overview of Osteoarthritis
Status Report on Role of Stimulants in Chronic Pain Management
Treatment of Osteoarthritis

Treatment of Osteoarthritis

Practical review of treatment options for spine, hand, hip, knee, and ankle osteoarthritis.

There is no treatment to prevent the development of osteoarthritis, or cure it once it has set in. Therefore, treatment is aimed at reducing pain, minimizing joint damage, and improving or maintaining function and quality of life.

The American College of Rheumatology (ACR) recently revised its recommendations for treatment of osteoarthritis (OA) of the hand, hip, and knee.1 According to the ACR, the treatment of arthritis should include the following:

  • Medications
  • Nonpharmacologic therapies
  • Physical or occupational therapy
  • Splints or joint assistive aids
  • Patient education and support
  • Weight loss
  • Surgery

Figure 1 illustrates the 6 types of interventions that should be considered for the treatment of OA. It is important for patients to realize that most of these treatments have a small to moderate impact on OA pain. Because no single modality provides complete relief of symptoms, use of multiple modalities to treat OA is recommended.2 Combining multiple modalities allows for synergy among the different treatments and often provides better pain relief.

In considering other treatment options, we have made recommendations based on the best evidence available to date. Most of the studies that have been conducted have been performed in knee OA or a mixed group of patients with knee or hip OA.

Medications

Medications—whether prescription or over-the-counter (OTC)—can make OA more manageable. Table 1 reviews the ACR recommendations for medication indications for  knee and hip OA.3,4 OTC medications typically are the first line of treatment, whereas prescription medications are reserved for more severe pain.

Acetaminophen: Before recommending any other medication, many physicians start patients on a trial of acetaminophen (Tylenol, others). It is typically considered a safe and effective medication for OA. Acetaminophen can help relieve mild to moderate OA pain. However, to avoid rare but serious adverse effects (AEs) of kidney and/or liver damage, patients must follow dosing instructions and avoid drinking excessive amounts of alcohol while taking acetaminophen.

Non-steroidal anti-inflammatory drugs (NSAIDs): OTC NSAIDs, such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve, others), are among the most commonly used to treat OA of all joints. Prescription-strength NSAIDs are the most common prescription medications used to treat OA. To avoid unwelcome AEs on the heart, stomach, intestines, and kidneys from NSAIDs, patients should take these medications exactly as directed.

COX-2 Inhibitors: Cyclooxygenase (COX)-2 inhibitors are the newest class of prescription-strength NSAIDs. COX-2 inhibitors help reduce pain and inflammation as effectively as traditional NSAIDs, but they are believed to carry fewer risks for gastroinestinal (GI) problems. Celecoxib (Celebrex, others) is the only COX-2 inhibitor currently on the market in the US.

Corticosteroids: Corticosteroids are powerful anti-inflammatory agents that can be taken by mouth or injected directly into the joint. They work by helping to temporarily reduce pain and inflammation in the joint. The effects of the corticosteroids may not last very long, and patients typically cannot have more than 4 injections in each joint per year. Also, over time, corticosteroids can become less effective as arthritis worsens. For patients with spinal OA, 2 types of injections are commonly performed: epidural steroid injection and facet joint injection. These injections may provide short-term pain relief.

Hyaluronic acid (HA) substitutes: Also known as viscosupplements, HA substitutes help reduce pain and swelling by lubricating joints and restoring the healthy joint fluid that typically diminishes with OA. Currently approved only for knee OA, HA substitutes usually are given in a series of 3 to 5 injections. A single-injection formula that offers up to 6 months of pain relief also is available.

Opioids: These agents generally are reserved for the management of moderate to severe pain caused by OA. Hydrocodone and acetaminophen (Vicodin, others) is the most commonly prescribed opioid in the United States. Tramadol (Ultram, others) is a less potent pain reliever for knee OA if more powerful opioids want to be avoided.

Topical pain-relieving creams, rubs, and sprays: These can be used along with or instead of oral medications. Patients older than 75 years of age may be advised to use topical NSAIDs applied to the skin instead of oral doses because they are thought to cause less GI bleeding and fewer additional AEs. Voltaren Gel is a topical prescription formulation of the NSAID diclofenac that is approved to treat knee OA. Capsaicin skin cream, derived from chili peppers, also may relieve pain.

Non-Pharmaceutical Therapy

While OA can’t be cured, it is possible to slow down its progression. In addition to medications, some treatments also help patients manage their symptoms and maintain a good quality of life. Table 2 reviews the ACR recommendations for nonpharmaceutical management of hip and knee OA. Table 3 outlines other potential treatment options.

 

Physical therapy (PT): A physical therapist can help patients maintain mobility, teach them how to reduce pain, and give them exercises that will strengthen their core muscles. PT may help increase flexibility and range of motion, and strengthen the muscles in the hip and leg. A physical therapist can help patients develop an exercise plan that works for their life and teach them how to move in ways that don’t increase pain.

Low-impact exercise (swimming or biking, for example) can help strengthen muscles that support the joints, which can reduce pain. Exercise also can increase flexibility, which is something that is gradually lost with OA.

Patients with mild cases of hip OA should be encouraged to protect the hip joint, to slow the progress of OA, for example, by limiting any activities that may cause pain, such as climbing stairs. If a patient is an avid golfer, skier, hiker, or runner, clinicians should recommend they consider switching to more low-impact activities, such as cycling, swimming, and weight training.

Although it may sound painful to patients, exercise can help improve the range of motion in the knees of OA patients. (See Exercise to Manage Knee Osteoarthritis)

If a patient is experiencing a painful flare-up, recommend the rest for a day or so may help. However, patients should be discouraged from remaining inactive for too long because joints can become more painful.

Cold and heat therapy may help pain during flare-ups. By reducing circulation, cold therapy can help decrease swelling. Heat therapy, on the other hand, increases blood flow to decrease stiffness in the joints and muscles surrounding the hip, knee, or ankle. Heat can be applied with warm towels, hot packs, heating pads, or a warm bath or shower. Cold packs, such as bags of ice or frozen vegetables wrapped in a towel, may help relieve pain. For neck pain, patient’s can fill a tube sock with lentils or rice. When placed in the microwave for one minute, the sock works as a wonderful heating pad for the neck.

Hydrotherapy or aquatic therapy is an excellent way to decrease OA symptoms. There are several advantages of hydrotherapy. For example, patients can combine hydrotherapy with gentle exercises in the water (which does not aggravate joints). Also, just being in warm water can help facilitate motion by easing muscle and joint stiffness.

Splints or joint assistive aids: A cane, walker, or other device may be needed to improve mobility of patients with OA of the hip, knee, or ankle. For patients with OA of the ankle, many clinicians also recommend custom-made shoes (such as a stiff-soled shoe with a rocker bottom), inserts that support the ankle and foot (orthotics), a foot orthosis—a plastic brace that goes along the back of the leg and the underside of the foot and also fits inside the shoe, and ankle braces or splints. Braces can range from soft lace-up braces to hard plastic boots. These are designed to limit the motion of the ankle joint.

Treatment for hand OA can involve learning how to avoid overexerting the affected joints, splinting, or surgery. Often, treatment starts with a combination of learning how to use your hand to protect your joints, along with medication. Patients also may be advised to wear a wrist and thumb brace. A hand therapist can provide exercises and ways to modify activities to protect hand joints.

Weight loss: Carrying extra weight puts more strain on the spine, hips, knees, and ankles. Therefore, patients who are overweight should be counseled on weight loss as a way to decrease their pain.

Other treatments: Some patients have found relief with acupuncture, massage, Tai chi, electromedicine, or herbal supplements (see Table 4). Before trying any herbal supplement, patients should consult with their doctor.

Surgery

OA of the Spine

Spine surgery is rarely required for spondylosis. However, if spondylosis is affecting bowel or bladder function, or if the spine has become unstable because of the spinal OA, then you may suggest surgery to relieve pressure on the nerves or spinal cord. Refer the patient to a spine surgeon who will make the best recommendation for the type of surgery needed.

OA of the Hand

The type of treatment needed will depend on how far the arthritis has progressed, how many joints are involved, patient age, activity level and other medical conditions, and whether the arthritis affects the dominant or non-dominant hand.

Surgery for hand OA may be an option when non-surgical treatments have not succeeded. Types of surgery for hand OA include:

  • Joint fusion. The surgeon removes the worn cartilage and fuses the bones on each side of the joint together. The joint will not move, but it will no longer hurt.
  • Joint reconstruction. The rough joint surface is removed and replaced with the patient’s own soft tissue or an implant made of ceramic, long-wearing metal or plastic.

After surgery, patients may be referred to a hand therapist. They may need to wear a splint or cast to help protect the hand while it heals. Most people are able to return to most if not all of their daily activities about 3 months after a major joint reconstruction.

OA of the Hip

If hip pain is severe, significantly limits activities, and does not respond to other arthritis treatments, hip replacement surgery can be considered (Table 4). An orthopedic surgeon who performs this surgery on a regular basis should be recommended. To prepare for a hip replacement, patients should make sure they have health insurance, time off from work, and finances to cover unpaid leave or medical deductibles or coinsurance.

Most hip replacement procedures are less than 90 minutes. The surgeon will remove damaged bone and cartilage and replace them with new metal, plastic, or ceramic joint surfaces. Surgery can significantly control pain, and complications are rare.

But the real work starts with a physical therapist who can help rehabilitate the new hip. Within 24 hours of surgery, patients generally walk for a few yards. Thanks to pain medications, this will not be so painful, but it will require some effort and exertion.

Patient usually are discharged from the hospital 3 to 4 days after surgery, where they will continue their PT for a few weeks. Most patients are happy with their hip replacement outcomes, often reporting they slept well for the first time in months the night after their hip replacement surgery.

For some patients who are younger and physically active, hip resurfacing may be an option. It involves scraping the surfaces of the hip joint and head of the femur and placing a metal cap over the bone. Much of the bone is preserved, so, if needed, a standard hip replacement can be done in the future. The procedure may provide a faster recovery and greater range of motion than a total hip replacement.

OA of the Knee

The goal of surgery for knee OA is to help patients return to normal activities. Table 5 reviews the different types of surgery used to treat knee OA.

  • Arthroscopy: This procedure is less invasive than joint replacement. The surgeon cleans up the knee joint by removing any debris (damaged cartilage or tissue) to prevent further joint deterioration.
  • Osteotomy: For an osteotomy, the surgeon will remove part of the bone. This is done to improve the alignment of the knee joint and to reposition the bones in the knee to decrease stress on the part of the knee that has developed arthritis. This can help decrease pain and other knee OA symptoms.
  • Arthroplasty (joint replacement): With this type of surgery, the surgeon replaces the entire knee joint (total knee arthroplasty) or just a part of the joint (partial knee arthroplasty) using artificial parts. These artificial parts are commonly made of plastic or metals, such as titanium.

Several factors are taken into account to determine whether a patient is a candidate for knee OA surgery: age, occupation, severity of pain and other symptoms, and the degree to which arthritis interferes with daily activities.

OA of the Ankle

Surgical procedures for ankle OA include:

  • Debridement: Using minimally invasive surgery (arthroscopy), the ankle joint area is cleaned of foreign tissue, inflamed tissue that lines the joint, and bone spurs.
  • Ankle fusion: The bones of the joint are fused completely, making one continuous bone. Pins, plates and screws, or rods are used to hold the bones in position while the joint fuses.
  • Aspiration and removing fluid from the joint.
  • Ankle replacement with an artificial joint: The ankle joint is replaced with an artificial joint. An ankle replacement allows a person to have more mobility and movement compared with ankle fusion. Ankle replacement most often is recommended for a person with advanced ankle arthritis.

After surgery, physical therapy may be recommended for several months to help patients regain ankle strength and restore range of motion. Patients usually can resume daily activities within 3 to 4 months, but they may need special braces or shoes.

Last updated on: August 11, 2015
Continue Reading:
PPM Editorial Board: Tips for Treating Osteoarthritis

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