The American College of Rheumatology (ACR), the European League Against Rheumatism (EULAR), the Osteoarthritis Research Society International (OARSI), and the American Academy of Orthopaedic Surgeons (AAOS) have all published recommendations for management of OA. The main goals of management are to minimize OA-related pain, improve physical functioning and optimize the quality of life of patients with OA. There are nonpharmacologic, pharmacologic, and surgical treatment options. OA management should be tailored to the individual patient, and optimal management likely includes a combination of these treatment modalities. Evidence suggests, for instance, that patient education, exercise programs, weight reduction, and wedge insoles all offer additional benefit in combination with an analgesic or nonsteroidal anti-inflammatory drug (NSAID).
OA patients should be taught about the goals of OA treatment, and the importance of changes in lifestyle, exercise, pacing of activities, weight loss, and various ways to minimize joint loading. The educational focus should be on initiating self-help and patient-driven treatments rather than simply accepting therapies delivered by providers. Thereafter, the emphasis should be on maintaining adherence to nonpharmacologic and pharmacologic therapies. Such information may be taught through group courses, individual consultations, and regular telephone calls. Participants of these programs report reduction in pain, improvement in function, and weight loss. The programs may also increase patient self-efficacy and physical activities, and decrease the number of OA-related physician visits.
Weight loss in overweight and obese individuals with OA of the lower limb is recommended by all existing guidelines for knee and hip OA management. In many patients, a structured weight management program may be necessary. An effective program focuses on developing healthy eating and physical activity habits. It should include a plan for the individual to lose weight slowly and steadily and to maintain the weight-loss over the long run. A realistic goal is weight loss of more than 5% to be achieved within a 20-week period. The program may include ongoing feedback, monitoring and support. Weight reduction has been shown to improve knee OA-related pain, stiffness, and disability. Studies also suggest similar benefits in patients with hip OA, but the evidence is not as strong as for knee OA.
Aerobic exercise and muscle strengthening can significantly improve the physical health and symptoms of patients with OA. Regular aerobic activities that the older adults can engage in include walking, bicycling, or swimming. Quadriceps muscle strengthening can be particularly helpful for patient with knee OA. In general, there is no significant difference in reducing arthritis-related symptoms and disability in knee and hip OA patients between aerobic and resistance training.
For patients with advanced OA, mobilization exercises (ie, stretching and flexibility training) and isometric strengthening exercise can initially be prescribed. Mobilization exercises increase length and elasticity in muscles and periarticular tissues. During isometric exercises, muscle length does not noticeably change and the affected joint does not move. Beneficial isometric exercises for the older adult include chair leg extensions, wall sits, and hip extensions. The exercise regimen may then progress toward isotonic strengthening and aerobic exercises. During isotonic exercise, muscle tension remains unchanged but muscle length changes. Beneficial isotonic exercises include squats, wall slides and leg presses. Finally, water-based exercise is a low-impact activity that takes the pressure off joints, muscles, and bones. It is particularly invaluable for those with severe OA and marked deconditioning.
Physical therapists may be helpful in providing instructions in appropriate exercises. They are essential in providing individualized treatment and a progressive home exercise program. Physical therapy evaluation may also result in provision of assistive devices, such as canes and walkers.
In summary, exercise can be a joint-specific range of motion and/or strengthening program, or a general aerobic conditioning regimen. It may be supervised on land or water, or it may be a home based, self-directed program. Regardless of the type of exercise regimen, extra attention is needed for older patients to enhance safety and compliance with the program, taking into account potential comorbidities. Those with knee or hip OA should also cautiously engage in moderately or severely strenuous exercises (eg, stair climbing, heavy weight lifting, and running).
Manual therapy entails passive physiologic and accessory joint movements, manual muscle stretching and soft-tissue mobilization. Therapy is often administered by a physical therapist in multiple sessions. Specific joints can be targeted. In combination with exercise, manual therapy can be highly beneficial in patients with knee and hip OA.
Braces, splints, and taping
A knee brace can reduce pain, improve stability and diminish the risk of falling for knee OA patients with varus or valgus instability. Separately, a brace and a neoprene sleeve have additional beneficial effect for knee OA compared with medical treatment alone. A brace tends to be more effective than a neoprene sleeve, however. Splints can be helpful for patients with trapezio-metacarpal joint OA of the hand. Medially directed patellar taping may benefit patients with knee OA.
All patients with knee or hip OA should receive advice regarding appropriate footwear. Among patients with knee OA, insoles can reduce pain and improve ambulation. Laterally wedged insoles can provide symptomatic benefit and decrease lateral thrust in the knee of patients with medial compartment OA. They can also potentially reduce NSAID usage. In parallel, medially wedged insoles can be beneficial for patients with lateral compartment knee OA. Comfort, fit, and adherence are all reasons that the use and benefit from orthotics have been limited.
Thermal modalities may be effective for relieving OA symptoms, but benefits may also be temporary. All patients with hand, knee and hip OA should be instructed in the use of thermal agents. Heat can be administered by various techniques including the application of heat packs or immersion in warm water or paraffin baths. There are also store-bought heat patches, belts, packs, and wraps. Patients should be instructed that use of heat therapies should be limited to 20-minute intervals to reduce the risk of burns. Cold (or cryotherapy) can be administered by application of ice packs or massage with ice. It can decrease inflammation, minimize muscle spasms and reduce pain. Patients should be instructed to also limit the use of ice or cold packs to 20 minutes. Use of heat or cold is often based on patient preference.
Walking aids can reduce OA-related pain in patients with knee and hip OA. A cane can significantly reduce joint loading and symptoms. It should be properly fitted to approximately the level of the greater trochanter of the hip. Patients should be instructed to use the cane with the hand opposite the affected knee or hip. The final bend to the elbow when walking with the cane should be approximately 15 to 20 degrees. When disability is more severe or when OA is bilateral, then a walker may be a better option. Assistive devices, such as zipper pulls, built-up handles on pencils/pens, cushioned carrying tools, and meal preparation devices, can be very beneficial for patients with hand OA. Occupational therapists are likely to be helpful in recommending lifestyle modification changes and giving ideas for assistive devices to patients with arthritis symptoms.
Tai chi, a practice which originated in China, is referred to as “moving meditation.” Practitioners move their bodies slowly, gently, and with awareness. It may be beneficial in treating lower extremity OA but the evidence is sparse.
In contrast, there is relatively good evidence that acupuncture relieves pain in patients with knee OA. Pain relief from this treatment diminishes with time, however. It is also unclear if it actually improves daily function. The addition of acupuncture to patient education and exercises may also provide no additional benefit. Nevertheless, acupuncture is recommended in the guidelines for the management of knee/hip OA by the ACR, EULAR, and OARSI in patients with moderate to severe knee/hip OA-related pain, especially those who are unable or unwilling to undergo joint replacement surgery.
Transcutaneous electrical nerve stimulation (TENS)
Such OA patients may also benefit from receiving TENS. It is a therapy that uses low-voltage electrical current for pain relief. Dose-dependent inhibition of nociceptive nerve transmission may provide a physiological rationale for the efficacy of TENS. No serious adverse events have been reported in its use. It can provide short-term pain relief in patients with knee or hip OA.
Capsaicin and rubefacients
Topical capsaicin creams contain a lipophilic alkaloid extracted from chili peppers which activates and sensitizes peripheral c-nociceptors. It is known to be effective in treating hand OA and may be used as an adjunct treatment for knee OA. Both 0.025% and 0.075% topical capsaicin have been shown to reduce pain in hand and knee OA. A dose of 0.025% topical capsaicin is better tolerated than 0.075%, however. Patients should be instructed to avoid inadvertent application of capsaicin in the eyes and mucous membranes. Rubefacients containing salicylates (eg, trolamine salicylate, hydroxyethyl salicylate, diethylamine salicylate) may also be used as adjunctive agents, despite scant supportive data. Skin burning, stinging, and erythema are potential side effects.
Topical NSAIDs, such as diclofenac sodium gel, can be effective alternatives and adjunct agents to oral analgesic agents. They can be particularly helpful in treating hand and knee OA. They have a high margin of safety and are not associated with acute renal failure or gastrointestinal (GI) adverse events. Thus, they may be particularly useful in patients with cardiac, renal or GI comorbidities. However, they may also be less efficacious than oral NSAIDs.
Oral Pharmacologic Therapies
Because it is inexpensive, safe and effective, acetaminophen may be a first-line agent in treating mild-moderate knee or hip OA. Many have tried using acetaminophen to relieve OA, but few have actually used the maximum daily dose of 4 g/day that was demonstrated to be efficacious in randomized controlled clinical trials. It is important to note that the Food and Drug Administration has reduced the maximum daily dose of acetaminophen to 3 g/day. It may relieve pain, but its effect may be relatively small. Hepatotoxicity is a potential side effect, but this is primarily seen only in patients with concurrent alcohol abuse or when used with other hepatotoxic drugs.
NSAIDs inhibit the activity of cyclooxygenase (COX) -1 and -2 enzymes, providing analgesic and anti-inflammatory effects. They can be very helpful for OA patients who minimally respond to acetaminophen alone and with moderate-to-severe levels of pain. In fact, because of their efficacy, OA patients often prefer using NSAIDs over acetaminophen. There is no strong evidence that a particular NSAID is more effective than other NSAIDs. Patients also vary in regard to how much relief they receive and the side effects they may encounter from taking one NSAID over another. Others may prefer particular NSAIDs (eg, meloxicam, naproxen) based on convenience, as some NSAIDs only need to be taken one to two times a day.
Patients may be started on a low-cost NSAID with a short half-life, such as ibuprofen or naproxen. If they have minimal response after a few weeks, then the medication dosage may be maximized. Switching to a different NSAID is another OA treatment management option.
While efficacious, NSAIDs should be prescribed with caution. GI complications such as peptic ulcer and bleeding are potential side effects. This risk increases with older age, concurrent use of other medications (eg, glucocorticoids), and longer therapy duration. Using either a COX-2 selective inhibitor or a nonselective NSAID in combination with a proton-pump inhibitor reduces this risk. Nephrotoxicity is another potential side effect. Patients with chronic kidney disease (CKD) stage IV or V (estimated glomerular filtration rate less than 30 cc/min) should avoid NSAIDs. Nonacetylated salicylates, sulindac and nabumetone appear to be less nephrotoxic than other NSAIDs, however.
Patients with cardiovascular disease are also at increased risk for cardiovascular adverse events (eg, myocardial infarct or stroke) associated with NSAIDs. Patients should be made aware of such risks. Finally, concomitant use of low-dose aspirin and short-acting NSAIDs (eg, ibuprofen) may also render aspirin less effective when used for cardioprotection and stroke prevention. Other types of NSAIDs should be considered in OA patients taking low-dose aspirin.
COX-2 selective inhibitors
A COX-2 inhibitor (ie, celecoxib) or a COX-2 selective NSAID (eg, meloxicam) can be a better treatment option for a subset of OA patients. They can effectively relieve painful OA symptoms. The risk of GI side effects is also significantly lower with the use of these medicines than with the use of nonselective NSAIDs. Prescribing these medications to patients with cardiovascular risk factors should be done with caution, however. Taking COX-2 inhibitors may increase the risk of myocardial infarct, stroke, and other related conditions.
Tramadol is a weak μ-opioid receptor inhibitor and inhibits the reuptake of serotonin and norepinephrine. It can significantly relieve pain in patients with hand, knee or hip OA. Patients may be started on 25 mg daily, and the dosage may be increased, thereafter. Just like other narcotic agents, it can also cause nausea, dizziness, somnolence, and vomiting. Long-term use may also lead to physical dependence. However, respiratory depression and constipation are considered less of a problem with tramadol.
Stronger narcotic medicines, such as oxycodone, hydrocodone, or morphine sulfate, may be considered in some OA patients after failure of other treatments. Patients who continue to have severe OA-related pain and disability despite trying other pharmacologic and nonpharmacologic OA treatments may be good candidates. Those who are unwilling or unable to undergo joint replacement surgery due to comorbid conditions (eg, significant cardiac or pulmonary disease) may also be reasonable candidates.
Narcotic agents, however, are poorly tolerated in older adults due to sensitivity to certain side effects, including constipation, urinary retention, confusion and sedation. The risk of falls may also be increased in this population who is already vulnerable to falls due to joint disease and other risk factors. If narcotic medicines are to be started in older adults, then the lowest dosages should be prescribed. Adjuvant therapies with nonnarcotic pain relievers should also be considered.
Glucosamine and chondroitin sulfate are naturally occurring constituents of cartilage proteoglycans. They are popular “nutritional supplements” used by many OA patients, but their use is highly controversial. Although several clinical trials had shown their efficacy in improving pain and function, these trials were all industry sponsored and utilized a pharmaceutical grade of glucosamine sulfate which is not available in the United States. Several other studies had demonstrated that they were no more effective than placebo. The ACR and OARSI conditionally recommend not using either supplement for the treatment of knee and hip OA. EULAR reports that glucosamine and chondroitin sulfate may provide symptomatic relief for knee OA. Therapy should be discontinued if patients do not respond after 6 months of therapy.
Other nutraceuticals previously used for arthritis include S-adenosylmethionine, pomegranate, green tea, turmeric, ginger, cat’s claw, devil’s claw, collagen hydrolysates, and avocado-soybean unsaponifiables. Evidence of efficacy of each of these treatments is highly limited.
Use of serotonin and norepinephrine reuptake inhibitors, such as duloxetine, is promising in the treatment of OA. They can reduce pain and functional impairment in central and neuropathic pain conditions. Evidence of their efficacy in OA has been demonstrated in clinical trials, however, there have only been a limited number of these trials.
Disease-modifying osteoarthritis drugs (DMOADs) can potentially inhibit the structural disease progression of OA and ideally improve OA-related symptoms. At present, there are no DMOAD therapies available in the market. However, several research studies are being conducted to determine their efficacy and safety. Many studies have focused primarily on preventing hyaline cartilage loss. Because the pathogenesis of OA involves multiple tissues, more recent studies are also targeting other tissues including the subchondral bone. Most DMOADs that are under investigation have an anticatabolic effect on cartilage and may also structurally modify subchondral bone. These include calcitonin, bisphosphonates, inducible nitric oxide synthase inhibitors, interleukin-1β antagonists, matrix metalloproteinase inhibitors, aggrecanase inhibitors, and doxycycline. Others, such as strontium ranelate, BMP-7 and FGF-18, have an anabolic effect on cartilage. Most of these experimental therapies are given systemically, but some are administered intra-articularly.
Intra-articular glucocorticoid (eg, methylprednisolone, triamcinolone) injections can significantly relieve pain due to OA. They can be most beneficial to OA patients who have one or a few joints that continue to be bothersome despite oral pharmacologic therapies. They are particularly efficacious in patients with knee or hip OA. Knee joint injection can be administered in an ambulatory care setting. Hip joint injection, though, is often done with ultrasonographic or fluoroscopic guidance. When proper technique is used, complications from intra-articular injections such as heavy bleeding and infection are rare. Benefits may be short-lived, though, and repeated treatments at frequent intervals may be necessary to maintain efficacy. More than three injections in a 6-month period is not recommended.
Viscosupplementation, the intra-articular injection of hyaluronic acid, is commonly used for symptomatic knee OA. Hyaluronic acid is a large molecular weight glycosaminoglycan which is a constituent of synovial fluid. Hyaluronic acid in OA joints is often of low molecular weight, losing its biomechanical and anti-inflammatory property. Viscosupplementation can lead to significant reduction in pain, improvement in physical function, and reduction in stiffness. It may even be more effective than oral pharmacologic agents in relieving OA-related pain and longer-lasting than intra-articular glucocorticoid injections. However, the product usually needs to be administered at weekly intervals for 3 to 5 weeks. There is a small risk of postinjection reactive inflammatory synovitis and a slight risk of joint infection. Although the AAOS and OARSI OA management guidelines do not recommend the use of viscosupplementation based on multiple meta-analyses, there may be patients that would benefit after failure of other more conservative options. Its cost-effectiveness is also controversial.
Surgical interventions should be considered in OA patients who continue to have significant pain and disability despite maximal use of nonpharmacologic and pharmacologic therapies. Patients must also be healthy enough to withstand surgery.
Arthroscopic debridement and joint lavage
Arthroscopic debridement is the removal of loose bodies, debris, mobile fragments of articular cartilage, unstable torn menisci, and impinging osteophytes. The procedure variably includes joint lavage. While it is a relatively common procedure, its practice is highly controversial. While a few uncontrolled studies have demonstrated short-term efficacy, most studies have shown that it is no better than placebo in providing symptomatic benefit for knee OA. These procedures are not recommended as treatment options in the AAOS and OARSI OA management guidelines.
Osteotomy is a surgical procedure in which bone is cut to shorten, lengthen, or change bone alignment. High tibial osteotomy is a potential surgical treatment for knee OA. It is appropriate for unilateral knee OA with varus malalignment. Realignment of the varus deformity would reduce stress on the medial compartment of the knee by redistributing the weight of the body from the arthritic medial compartment to the healthier lateral compartment. The procedure can reduce pain, improve function, and delay the need for joint replacement. Overall failure rate at 10 years is approximately 25%.
Intertrochanteric varus or valgus osteotomy has been used for hip OA treatment for nearly a century. Pelvic or femoral osteotomies have also been used to correct the biomechanics and joint congruency in young patients with hip dysplasias to prevent the development of hip OA. Evidence in the efficacy of these procedures, however, is limited.
Uncompartmental knee arthroplasty involves replacement of a part or section of the knee that is arthritic. It may be considered in patients with discrete knee pain and disease that is localized to the medial compartment. Compared to total knee arthroplasty, it may also improve knee pain and function but requires a smaller surgical incision. Consequently, there is less postoperative pain, and hospital stay is shorter. The rehabilitation process also tends to be more rapid. Postsurgical complications, such as deep vein thrombosis and infection, are also fewer with unicompartmental than with total knee replacement surgery. The concern about unicompartmental knee arthroplasty, though, is that it may make subsequent total knee replacement surgery more complex.
Total joint replacement surgery is an irreversible procedure used in those with severe OA who have failed conservative treatment modalities. It is usually selected for those with OA of the hip, knee or shoulder. Patients who undergo surgery often attain substantial improvements in pain and physical functioning. Maximal improvements are usually observed in the first 3 to 6 months with long-term benefit plateauing after 9 to 12 months. Quality of life indicators following joint replacement also improve approximately a year after surgery. With current advances, the implant typically lasts 15 years or more. Arthroplasty revision may be required due to aseptic loosening or infection. Risk of revision is also higher in patients with OA younger than 65 years than in those aged 65 years or older.
Joint fusion surgery, also known as arthrodesis, may be selected in patients with severe OA of the wrist, ankle, or first MTP joint. It may also be used as a salvage procedure when knee joint replacement has failed. During the procedure, two bones on each end of a joint are fused, eliminating the joint itself. While a fused joint loses flexibility, it can bear weight better and may be completely pain free.
Surgery is considered when nonsurgical options have not significantly helped patients with OA of the thumb base (ie, carpometacarpal or trapeziometacarpal joint OA). Surgical options include trapeziectomy, trapeziectomy with ligament reconstruction, joint replacement and joint fusion. The type of surgery chosen will likely depend on the patient anatomy, the joint involved, and the patient’s occupation and recreational activities.