Treatment of Osteoarthritis
Our understanding of bone and joint health and the conditions that affect it continues to evolve leading to a better understanding of how to manage these conditions and improve the quality of life of affected individuals. This overview focuses on the management and treatment of osteoarthritis (OA).
· Medications for Treatment of Osteoarthritis
· The Role of Surgery
· Occupational Therapy and Assistive Devices
Medications for the Treatment of Osteoarthritis
Many medications have the potential to decrease pain generated by irritated joints and muscles. A wide variety of drug therapies are now available. The key to success is matching the degree of illness with the corresponding drug. Each drug category has associated side effects and physicians want to limit those exposures to a minimum. Essentially, the goal is to take the most appropriate number of medicines associated with the least number of side effects to achieve the best therapeutic response.
· Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are the most commonly used treatments for OA inflammation, stiffness and related pain. NSAIDs include aspirin, ibuprofen, naproxen and celecoxib. They are available over-the-counter or by prescription and may be taken orally or applied topically to the skin in a cream, lotion or gel form.
NSAIDs are generally safe to use for minor flares of pain, but they do have many possible side effects if you take them for a long time or in high doses. Side effects include bleeding, damage to the kidneys, gastritis/bleeding ulcers, fluid retention and high blood pressure. Learn all about NSAIDS
· Cortisone Injections - Steroids known as glucocorticoids may be used on short-term basis to reduce joint inflammation. Depending on the situation, they may be taken orally, injected into a muscle, or injected directly into an affected joint. Steroids can rapidly improve symptoms. For OA, corticosteroids are usually injected by your physician directly into the affected joint(s). [Learn about Cortisol (steroid) injections](Cortisone (Glucocorticoid%29 Injections Glucocorticoids are medicines used to reduce pain and inflammation. They may also be called corticosteroids or even “steroids” for short. They're most commonly injected into joints — such as your ankle, elbow, hip, knee, shoulder, spine and wrist. Even the small joints in your hands and feet might benefit from cortisone shots. The purpose of the corticosteroid injection is to reduce the irritation caused by local joint inflammation which is what happens when the cartilage wears away. The effect, though temporary, can provide significant relief for some patients. However, these injections do not work well for all patients. That may be because the arthritis is too far advanced or because it is difficult to locate the joint space due to bulky joints or other deformities (though ultrasound can help guide the doctor as to where to place the injection%29. How long will a cortisone injection work? The beneficial effect of a cortisone injection lasts for an average of two months. Any candidate for a steroid injection may receive physical therapy, supportive bracing and oral or topical medication to maximize their response to the injection. The extent of arthritis progression and overall health are two important factors that affect how long the relief from the injection will last. How often can cortisone injections be given? Individuals shouldn’t have corticosteroid injections into any given joint more than once every three to four months. Too many injections can increase the risk of side effects, such as avascular necrosis, which is a lack of blood flow to a part of the bone that causes it to collapse. Other side effects include nerve damage and thinning of nearby bone. Because the injections are formulated as slow-release crystals, patients can, in the short term, develop irritation in the joint similar to gout, and, rarely, develop infection. American College of Rheumatology Recommendations Oral or topical NSAIDs or the use of steroid injections for patients with hip or knee OA who do not have a satisfactory response to full-dose acetaminophen are recommended. The ACR does not recommend corticosteroid injections for people with hand OA. What Are Possible Side Effects of Corticosteroid Injections? • Nerve damage • Thinning of nearby bone and/or fat tissue • Irritation in the joint similar to gout (because the injections are formulated as slow-release crystals%29 • Infection (though this is rare%29. • Increased glucose levels in diabetics • Avascular necrosis of the joint The chances of having these side effects depend on how often you get the injections and whether you have other medical conditions. Monitor for Side Effects You and your doctor should be on the lookout for any of the above side effects. If you experience any pain or other symptoms around the joint that was injected, bring it to your doctor’s attention. References: 1. https://www.rheumatology.org/Portals/0/Files/ACR%20Recommendations%20for%20the%20Use%20of%20Nonpharmacologic%20and%20Pharmacologic%20Therapies%20in%20OA%20of%20the%20Hand,%20Hip%20and%20Knee.pdf 2. http://www.arthritis.org/living-with-arthritis/treatments/medication/drug-types/corticosteroids/corticosteroid-injections.php By David Borenstein MD, past president American College Rheumatology & CH Weaver MD Medical Editor)
· Acetaminophen - has been shown to be effective for people with mild to moderate OA pain. It is sold under the brand name Tylenol® and is typically used to treat pain and reduce fever. It is sold over the counter and is taken orally. It is generally safe to use for minor flares of pain and typically does not have side effects, though large amounts taken over a long period of time can potentially cause liver damage. The most common side effects, though rare, are rash, nausea, and headaches. Learn more about Tylenol
· Cymbalta® (duloxetine) - a type of drug known as a selective SNRI (Serotonin and norepinephrine reuptake inhibitor), for chronic musculoskeletal pain including OA. It was first approved by the FDA in 2004 as a treatment for depression, and is also used for other health concerns, including other mood disorders, nerve pain and fibromyalgia. It was approved for use in OA based on two clinical trials that showed it was associated with significant pain reduction and improved function in patients with pain due to knee OA. Learn about Cymbalta
· Tramadol is an opioid pain medicine used to treat moderate to moderately severe pain. It is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. Tramadol can help to decrease OA pain intensity, relieve symptoms, and improve function. It is sometimes prescribed to treat OA pain, particularly for patients with severe pain for whom NSAIDs and acetaminophen do not provide symptom relief. Learn all about Tramadol
· Hyaluronic acid Intra-Articular Joint Injections - Hyaluronic acid (HA) is a natural gel-like, lubricating substance that occurs in your joint fluid and cartilage, acting as a shock absorber and lubricant. However, the acid appears to break down in people with osteoarthritis. Injections of hyaluronic acid directly into the knee joint are selectively used in the treatment of OA. Learn more about Hyaluroinc joint injections
If joint damage becomes severe, surgery on the affected joint may relieve pain and (in some cases) improve joint function. Joint replacement, for example, involves removing a damaged joint and replacing it with an artificial one. This can reduce pain while also preserving or improving the function of the joint. Another procedure—joint fusion—involves fusing together the bones in a joint. This eliminates the ability of the joint to move but provides stability and pain relief. Surgery may also be used to repair or remove damaged tissue.1
Surgical therapy of osteoarthritis of the spine is controversial. Some spine surgeons believe that fusing portions of the spine that are causing only back pain result in individuals with less spine pain. In many circumstances, the individual has traded one spine pain for another. In the neck, the benefits of spinal fusion may be better, but patients remain at risk of progressive osteoarthritis at other levels of the spine.
As a generalization, spine surgery is offered for individuals with leg or arm pain, not those with pain limited to the spine alone. An exception to this rule is spinal instability. Stabilization of the spine can offer symptom relief for those with associated spine pain. The decision to do surgery in this circumstance should only occur after an informed discussion with a spine surgeon
Occupational Therapy and Assistive Devices
Arthritis may slow you down, but it doesn’t have to stop you. If you find yourself struggling with everyday activities, there are devices—called assistive devices—that can help you.
Although not everyone needs an assistive device, they can help you to conserve energy and get through your day with less pain. An assistive device is a product or tool designed to assist with tasks and promote independent function. There are countless types of assistive devices and some are even specifically designed for people to help with mobility and grip.
Occupational therapists specialize in helping people maintain independence and perform daily activities. They often find alternatives or modifications for tasks—and sometimes this means providing splints or other assistive devices to help promote independent function. An occupational therapist can help you determine which assistive devices you need and where to get them.
The non-surgical therapy of OA may include a number of options.
- Physical therapy that strengthens the muscles around a joint or the spine can help protect the joints.
- Exercises that maximize the range of motion of joints helps maintain function.
- Obesity can negatively affect functioning of the spine by placing extra strain on joints and spine structures. Losing weight results in less pressure relieving strain on the joints. In addition, fat cells release chemicals that are pro-inflammatory that may have detrimental effects on joint structures. Lowering levels of these chemicals can have a beneficial effect on the musculoskeletal system.
Borenstein DG, Wiesel SW, Boden SD: Low Back and Neck Pain: Comprehensive Diagnosis and Management. 3rd Edition. Philadelphia: W. B. Saunders, 2004.