What To Do About Osteoarthritis

What do you think is the number one cause of pain and disability in older adults around the world? If you said arthritis, you would be right. Areas affected most often include the hip and knee, but other joints such as the spine, shoulders, elbows, wrists, and ankles can be affected. Small joints of the hands can also cause pain, stiffness, and loss of motion and function from osteoarthritis. With so many adults affected, health care providers have tried to conduct research and report results in an organized way that includes evidence-based treatment guidelines.

In this article, current practice guidelines published by the Osteoarthritis Research Society International (OARSI) are presented and reviewed by three experts on this topic. The most recent OARSI guidelines were put out in 2007. A group of experts on a committee reviewed high-quality studies in putting together the treatment guidelines. The evidence covers pharmacologic (drug therapy), nonpharmacologic (nondrug therapy), and surgical treatment of osteoarthritis. They also incorporated expert opinion in saying what works best for patients with this condition.

You might think this sounds like a pretty easy task. To use a popular expression today: not so much. The committee members found over 100 ways to treat this problem. They tried to stick with the results of high-quality studies, but they also incorporated patient opinions, preferences, and values. Not too surprising, no one single treatment approach was recommended. Using a combination of drug therapies along with other conservative (nonoperative) approaches was preferred and most effective for the majority of patients.

The bottom-line is to find a cost-effective way to reduce pain and manage other symptoms that accompany osteoarthritis. The more patients understand the disease, the better able they are to manage their own condition. So patient education is a key component of any successful treatment program. Finding ways to take pressure off the affected joints is a central feature of any successful program. For some patients, this means some lifestyle modifications, exercise, weight loss, and using supportive devices when needed. Studies show that combining exercise with weight loss works much better than just exercise or just weight loss alone.

Physical therapy can be very helpful to get a patient headed in the right direction and set up with an individual program that works best for each one. The therapist can provide exercises to help with strengthening muscles that support and offload the joints while also using exercise to help the patient lose weight without aggravating joints and increasing pain and stiffness. The therapist can provide a postural assessment and advice or suggestions about ways to improve posture to reduce stress on the joints.

The therapist may advise changes in footwear or sleeping habits that help manage symptoms. In some cases, the therapist has a role in providing appropriate braces insoles or walking aids to help improve patient function. When symptoms are at their worst, modalities such as heat or electrical stimulation may be used to get control of symptoms before moving forward with the rest of the program.

Pharmacologic approaches with drug therapy usually start with a simple pain reliever such as acetaminophen (Tylenol). This medication only reduces painful symptoms. Patients often have to rely on ibuprofen or other antiinflammatories to relieve stiffness and aching that puts a damper on daily and social activities. For patients with more severe inflammation and swelling, steroid injections offer quick, short-term relief but no long-lasting effects. Likewise, the use of an injection called hyaluronic acid (hyaluronate) can help restore some of the slippery joint surface needed for sliding and gliding during joint movement. One to three injections seem to help with immediate relief of symptoms that lasts longer than steroid injections.

When everything else has been tried and fails to provide symptom relief needed to cope and move through each day, then surgery may be the only answer. Joint debridement (scraping bone spurs away and smoothing the joint), osteotomy (cutting a wedge of bone out to help realign the weight-bearing surfaces), and joint replacement are the three main surgical options. If a joint replacement fails, then fusion of the joint remains the last choice. Fusion is not ideal because motion is lost and therefore, function is reduced.

The authors mention that there are 25 treatment guidelines proposed in the 2007 OARSI document but they were not reprinted in this article. The authors say that the guidelines are flexible and can be adapted and used in many different health care settings. Cost, patient preferences, and availability of resources are all important factors in putting any of the guidelines to good use. As with any condition-specific guidelines, evidence-based research is required. And that means that as new findings are published, the guidelines may change periodically to reflect new data and information.

Reference: 

Elizabeth Tanjong-Ghogomu, MD, MSc, et al. Overview of the OARSI Guidelines for the Management of Hip and Knee Osteoarthritis. In Pain Management News Special Edition. December 2009. Vol. 7. No. 12. Pp. 35-38.

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