Patients with OA seek medical attention because of pain. In addition to pain, OA is accompanied by structural changes not only within the joint, including cartilage loss and formation of osteophytes, but also changes in muscle, bone, tendons, ligaments, menisci, synovium, and the joint capsule. These changes result in altered joint mechanics and muscle weakness, causing decreased physical function and disability. Therefore, functional improvement is as important as pain management in OA, particularly in the geriatric population. The multidisciplinary team approach often used in geriatric medicine clearly applies to managing the OA patient. The Osteoarthritis Research Society International (OARSI) and European League Against Rheumatism (EULAR) have developed guidelines for the management of OA of the hand, hip, or knee. Table 26–3 summarizes the most recent American College of Rheumatology (ACR) guidelines on the treatment of OA.
Table 26–3.Summary of American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. ||Download (.pdf) Table 26–3. Summary of American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
| ||Nonpharmacologic Recommendations ||Pharmacologic Recommendations |
|Strong || || |
|Conditional || |
Manual therapy in combination with supervised exercise
Medially directed patellar tapingc
Medially wedged insoles in case of lateral compartment OAc
Laterally wedged subtalar strapped insoles in case of medial compartment OAc
Walking aids, as needed
Tai chi programs
Traditional Chinese acupuncturea
Transcutaneous electrical stimulationa
|No recommendations || |
Balance exercises, either alone or in combination with strengthening exercises
Laterally wedged insoles
Manual therapy alone
Laterally directed patellar taping
The nonpharmacologic program is critically important and needs to become a part of an OA patient’s lifestyle. It should be used prior to or in conjunction with pharmacologic treatments. Nonpharmacologic modalities strongly recommended for the management of knee OA include aerobic, aquatic, and/or resistance exercises, as well as weight loss for overweight patients.
Exercise is integral in reducing impairment, improving function, and preventing disability. A systematic review and meta-analysis for exercise therapy and OA of the hip or knee concluded that strength training or aerobic exercise regimens for patients with OA led to improved physical health and symptoms of OA. There was no significant difference in terms of reducing arthritis-related symptoms and disability in OA patients between aerobic and resistance training. For patients with advanced OA, range of motion and isometric strengthening exercise can initially be prescribed, and an exercise regimen may progress sequentially through isotonic strengthening, aerobic exercises, and, ultimately, to recreational exercise. Extra attention is needed for the older patient to enhance both safety and compliance with an exercise program; indeed, interventions such as supervised or individualized exercise therapy and self-management techniques may enhance exercise adherence. Tai Chi exercises specifically designed for patients with arthritis may also offer some symptomatic relief and are conditionally recommended by the ACR. Water exercises are of value for those with severe arthritis and marked deconditioning. In addition, elliptical training, cycling, and upper body exercise may help in such cases.
A 2007 meta-analysis of weight reduction and knee OA showed that physical disability diminished after a moderate weight reduction regime, with weight loss of >5% from the baseline to be achieved within a 20-week period; that is, 0.25% per week. In addition, pain and physical disability were reduced if the patient lost more than 6 kg (13.2 lb). The combination of diet and modest exercise in older adults with knee OA has been known to be most effective in weight control. However, weight loss in the overweight, inactive older patient is a particular problem as weight loss without exercise can cause inadvertent decrease in muscle mass (sarcopenia).
Other nonpharmacologic modalities—
Other nonpharmacologic modalities conditionally recommended for knee OA include medial wedge insoles for valgus knee OA, subtalar strapped lateral insoles for varus knee OA, medially directed patellar taping, manual therapy, walking aids, thermal agents, self- management programs, and psychosocial interventions. Knee bracing was recommended by EULAR, but ACR has no recommendation because of conflicting data on efficacy. Patients may benefit from using a cane in one hand for OA of the contralateral hip or knee, but it needs to be properly fitted (ie, when standing, the elbow should be bent to approximately 20 degrees). When disability is more severe, a walker may be needed to maintain function. Physiotherapeutic measures include therapeutic ultrasound, manual therapy, application of heat and/or cold modalities, stretching/traction, and transcutaneous electrical nerve stimulation (TENS). Patient education and psychosocial support are as important as medical therapy, particularly in older adults. The patient needs to be educated on the nature of OA and its impact on their physical activity. Therapeutic options and the risks and benefits of the different approaches to management should be provided in depth. The initial patient evaluation should include an assessment of symptoms of depression and specific coping strategies that may limit future compliance to therapeutic recommendations. Lifestyle modifications are an integral part of the nonpharmacologic program. A patient with lumbar spine, hip, or knee OA should avoid deep chairs and recliners from which posture is poor and rising is difficult. Resting the affected joint can ease pain short-term, but prolonged rest may lead to muscle atrophy and decreased joint mobility.
Pharmacologic therapy is added when the nonpharmacologic program does not provide adequate relief of pain. Pharmacologic modalities conditionally recommended for the initial management of patients with knee OA include acetaminophen, oral and topical NSAIDs, tramadol, intraarticular corticosteroid injections, intraarticular hyaluronate injections, and duloxetine. Opioids were conditionally recommended in patients who had an inadequate response to initial therapy, but opioids should be used with caution in older adults.
Acetaminophen is the initial therapy for mild OA because it is inexpensive, relatively safe, and effective. Although most patients have tried acetaminophen prior to visiting the physician, they rarely have tried the maximum recommended dose (4 g/day). It is important to review the patient’s medications exhaustively, including combination products with opioid analgesics and nonprescription medications, when the physician considers initiating acetaminophen in the full dosage. Hepatotoxicity can occur, but, at the therapeutic range, is primarily seen mainly in patients with concurrent alcohol abuse or in conjunction with other hepatotoxic medications. In OA subjects with moderate-to-severe levels of pain, NSAIDs appear to be more effective than acetaminophen. When acetaminophen fails to control symptoms, the use of NSAIDs or intraarticular corticosteroid injections is recommended. There is no convincing evidence that any of the available NSAIDs is more effective than any other for OA of the knee or hip, and patients’ responses to the different agents in terms of both efficacy and toxicity are unpredictable. Thus, low-cost products with a short half-life, such as ibuprofen or naproxen, may be an appropriate initial choice. If 2 to 4 weeks of low-dose therapy does not yield adequate control of pain, the dose should be gradually increased toward the maximum of that medication, taking into account the patient’s other comorbid conditions. Patients should be well informed of adverse effects, including peptic ulcer, gastrointestinal bleeding, renal dysfunction, edema, abnormal liver function tests, elevated blood pressure, and the potential cardiovascular risk when the therapy is initiated. Presence of multiple comorbidities and the risk of NSAID-associated gastrointestinal (GI) side effects limit their use in older patients, those on aspirin or anticoagulants, and those on concomitant use of glucocorticoids. The risk of GI side effects is greatest in the first month of use. Central nervous system dysfunction in older adults can occur even with the standard dosages, particularly with indomethacin. Nephrotoxicity is more likely to occur in patients with preexisting diabetes mellitus, congestive heart failure, liver cirrhosis, diuretic therapy, or chronic kidney disease while using an NSAID. The nonacetylated salicylates, sulindac, and nabumetone appear to be less toxic to the kidney. Short-acting NSAIDs, such as ibuprofen, interfere with the desirable antiplatelet effects of low-dose aspirin and should not be administered within 3 hours of aspirin. The risk of GI bleeding can be lessened by use of a cyclooxygenase-2 selective inhibitors (eg, celecoxib or meloxicam) or concomitant use of a proton pump inhibitor or misoprostol. However, gastroprotective agents are not protective below the ligament of Treitz and lower GI bleeding risk, which is common with NSAID use in older adults, remains high even with use of these agents. The potential reduction in GI risks cannot justify the use of cyclooxygenase inhibitors as an initial agent, given concerns about the increased risk of cardiovascular events and their cost. Furthermore, in the presence of low-dose aspirin, reduction of GI adverse effects may not be maintained. Topical NSAIDs use is also conditionally recommended for the hip or knee OA. Topical NSAIDs are safer but may be less efficacious than oral NSAIDs. Topical capsaicin or other salicylate-containing topical agents (eg, trolamine salicylate, hydroxyethylsalicylate, diethylamine salicylate) can relieve OA pain. ACR guidelines supports the use of topical capsaicin only for hand OA. Tramadol is a dual-acting weak mu-receptor inhibitor with serotonin reuptake inhibition. It has been shown to have an additive effect with acetaminophen. Side effects of tramadol include nausea, vomiting, lightheadedness, dizziness or headache. Because of frequent central nervous system-induced side effects in older people, the initial dose should be lowered, or avoided if possible, in the geriatric population. Although the ACR and EULAR guidelines on treatment of knee OA support the use of opioids when other treatments have failed or are not appropriate, they are poorly tolerated in older patients because of increased sensitivity to adverse side effects, particularly sedation, confusion, and constipation. The lowest dose of opioids should be used, whenever possible. Increased risk of falls from opioids use is of great concern for those who are already vulnerable to falls as a result of underlying joint failure. Opioid analgesics may be beneficial in older patients who were either not willing to undergo or had contraindications for total joint arthroplasty after having failed all other nonpharmacologic and pharmacologic therapies. Oral administration of a serotonin and norepinephrine reuptake inhibitor (eg, duloxetine) shows promise in the treatment of OA.
Intraarticular glucocorticoid injections help to relieve pain and increase joint flexibility for variable periods of time. They may be of greater value when synovial effusions or signs of inflammation are present and in patients with 1 or a few joints that are painful despite the use of an NSAID. Intraarticular glucocorticoid injections are recommended to be limited to less than 5 times a year in any given joint. With proper use of aseptic technique, septic arthritis is a very rare complication. Steroid injections should be used with caution in diabetic patients. Hip joint injection requires ultrasonographic or fluoroscopic guidance, and efficacy of glucocorticoid injections at sites other than the knee or hip is less certain. Hyaluronic acid is a simple, conserved long-chain high-molecular-weight disaccharide that is a natural secretion of the synovium in a normal joint. However, hyaluronic acid in the joints of OA patients is most often of low molecular weight, losing its biomechanical and antiinflammatory properties. Intraarticular injection of moderate to high-molecular-weight hyaluronan preparations, also known as viscosupplementation, are widely used to treat OA of the knee, but there is still some uncertainty about whether the injections are superior to placebo, oral NSAIDs, or intraarticular glucocorticoids. Significant pain reduction is often not achieved until weeks following the initial injection. The injections are generally well tolerated but there is a risk of postinjection reactive inflammatory synovitis and a small risk of joint infection.
Nutraceuticals are natural substances used to promote health and prevent disease. There are several nutraceuticals that are used for treatment of OA. The use of glucosamine and chondroitin for OA has been controversial, and results of randomized trials have varied. The balance of evidence from high-quality trials has shown little to no evidence of clinically meaningful benefit. ACR experts conditionally recommend that patients with knee or hip OA should not use the chondroitin sulfate or glucosamine. Other nutraceuticals that have been tried in the management of OA include flavocoxid, S-adenosylmethionine (SAM-e), Boswellia, collagen hydrolysate, Avocado-soybean, curcuma (tumeric), ginger, and evening primrose oil, but each of these have very limited evidence of efficacy.
Colchicine has been tried in patients who have inflammatory OA that is refractory to NSAIDs and/or intraarticular glucocorticoids and who have evidence of CPPD crystals. Hydroxychloroquine has also been tried anecdotally in patients with inflammatory or erosive OA that has been unresponsive to NSAIDs.
Complementary and Alternative Treatment
Acupuncture is conditionally recommended only for patients with refractory symptoms who desire nontraditional therapies or who cannot undergo surgical interventions. According to a recent meta-analysis on the effectiveness of acupuncture for OA of the knee, acupuncture seems to provide improvement in function and pain relief as an adjunctive therapy for OA of the knee when compared with credible sham acupuncture and education control groups.
Recommendations for hip OA are similar to those for the management of knee OA.
Modalities conditionally recommended for the management of hand OA include instruction in joint protection techniques, provision of assistive devices, use of thermal modalities and trapeziometacarpal joint splints, and use of oral and topical NSAIDs, tramadol, and topical capsaicin.
Randomized trials have shown that arthroscopic surgery is no better than placebo for symptomatic benefit in knee OA. Recent epidemiologic studies have shown that meniscal damage is common in individuals with knee OA and may often be asymptomatic. Meniscectomy for traumatic injuries is associated with increased risk of developing knee OA. Therefore, the benefits of partial meniscectomy in knee OA is also unclear.
Total joint arthroplasty—
Although there are no clear criteria for surgical indication, surgical interventions are generally reserved for individuals with severe symptomatic OA who have marked limitations in function, such as performing the activities of daily living, and who have failed nonpharmacologic and pharmacologic therapies. Potential surgical candidates should have had an adequate trial of exercise and physical therapy. The primary goals of joint replacement are pain relief and functional improvement. Total joint arthroplasty is usually selected for OA of the hip, knee, and shoulder, and arthrodesis (fusion) is usually preferred for the wrist, ankle, and first metatarsophalangeal (MTP) joint. Hemiarthroplasty may be beneficial in joint replacement surgery for hip and knee OA and is successful in all age groups, showing excellent outcomes, even in the presence of obesity; however, there is an increased risk of mortality in older adults, and older age is related to worse function, particularly in women. In selected patients, corrective osteotomy and joint resurfacing can be considered instead of total arthroplasty. Various surgical interventions have been used to treat pain and dysfunction arising from OA at the base of the thumb (CMC or trapeziometacarpal joint OA). Patients who fail to respond to more conservative treatment may be candidates for trapeziectomy or CMC joint replacement.