Osteoarthritis

What Treatment Is available For Osteoarthritis?

Successful treatment programs are tailored to meet the needs of the individual.

By treating arthritis early and following a well-designed treatment plan, you can:

• Reduce your symptoms
• Increase joint movement
• Lessen joint-damaging effects

Osteoarthritic joints are not always painful, and when pain is present, it can vary in intensity. In some people severe osteoarthritis is completely pain-free, whereas in others even minor joint changes are quite painful.The response to arthritis pain is broad and very personal.

Because of this, it is important to have an individually designed treatment program. What works for one person may not necessarily work for another, even if both have osteoarthritis of the same joint.

Treatments include:

• Weight control
• Proper exercise
• Heat and cold therapy
• Pain medication
• Other pain relief options
• Stress control
• Injections into the joint
• Surgery

Weight Control

Weight control is important to successful arthritis management. Research suggests that:

• Being overweight is a risk factor for osteoarthritis
• Overweight young adults are likely to develop osteoarthritis of the knee as they age

Controlling your weight can:

• Lessen pain by reducing stress on the weight-bearing joints (hips, knees, back, feet)
• Increase self-esteem and avoid the risk of psychological suffering and/or depression that can affect overweight individuals

Weight loss should be coupled with a regimen of more physical activity. A productive goal is a total of 30 minutes of daily exercise. Exercise may need to be altered in the presence of OA, but most can exercise.

Excerise

Regular exercise is very important for successful control of osteoarthritis.

Strengthening and stretching exercises can help by:

• Relieving pain and improving joint movement
• Building up the muscles around the joint, making the joint more stable and resisting further damage.

Specific exercises may be prescribed to improve strength and range of motion in particular joints and muscles. Three types of exercise are used to treat osteoarthritis:

1. Stretching exercise
2. Isometric exercise
3. Aerobic (endurance) exercise

1. Stretching exercise. Also called range-of-motion (ROM) exercise, it helps to maintain joint flexibility and reach. It includes anything that puts a joint through its fullest range of motion (for example, stretching the shoulder joint by holding the arms out at the sides and circling them in a windmill fashion). Stretching exercise often is more easily performed if the person takes a pain reliever or applies heat to the joint before starting to exercise.

2. Isometric exercise. This is exercise in which muscles are tensed for a period without actually moving them. It can be performed without actually bending a painful joint. As muscles are exercised against resistance, their size and power will increase.

3. Aerobic exercise. This is endurance-building exercise that improves cardiopulmonary (heart/lung) fitness. For most individuals with osteoarthritis, the best aerobic exercises are:

• Swimming (especially in a heated pool)
• Walking on level ground

Such gentle exercises are less stressful on the joints. Water exercise is especially recommended for people who have osteoarthritis of the large joints (hips, knees). The buoyancy of the water makes it possible to exercise while the body weight is supported.

Since pain may worsen with increased activity, people with advanced osteoarthritis may need to take several rest periods during the day. On the other hand, too much inactivity can worsen osteoarthritis by causing increasing stiffness. An optimal treatment plan should achieve a balance between daily exercise and adequate rest.

Heat And Cold Therapy

Heat and cold treatments are well-known to reduce the pain, stiffness, and occasional swelling associated with osteoarthritis. But this is generally temporary. There is no ‘set’ formula for therapy. Heat works better for some individuals, whereas others favor cold.

Heat often is used to relieve pain or relax muscles before the start of exercise.

• Heating pads or hot packs can be positioned over stiff joints. Some people prefer “moist heat” in the form of warm towels, a warm shower or bath, or a heated whirlpool or hot tub.
• Other heat treatments include ultrasound and immersion of painful hands into warm wax. All are able to bring soothing heat to sore joints.
• Heat should be applied at a comfortable temperature and seems to be most beneficial when used over the muscles adjacent to the joint.

Cold can lessen pain in a sore joint by numbing the local tissues.

• It may be applied in the form of a reusable pack or ice.
• Ice and cold packs never should be placed directly on the skin, as they are likely to cause skin damage. Instead, ice and cold packs should be wrapped in a towel before they are applied.

Pain Medication

Medicines to control OA pain must be pain-specific, since osteoarthritis can cause both sudden and chronic pain.

• If a person experiences unexpected, severe pain from a damaged joint, he or she might benefit from strong pain relievers and muscle relaxants.
• By contrast, such medications usually are not useful or appropriate for chronic pain, which is more effectively treated by self-management techniques such as proper joint use, joint protection, exercise, medication scheduling, and weight control.

Many medications are used to treat arthritis. Some must be prescribed by a physician, whereas other “over-the-counter” (OTC) products can be bought without a prescription.

OTC pain relievers like acetaminophen (Tylenol®) and aspirin are familiar choices for the treatment of osteoarthritis.

• Acetaminophen generally is considered safe, although it may pose risks to the kidneys or to the liver in some individuals with liver disease.
• Aspirin is a popular medicine for many arthritic disorders because of its ability to relieve pain as well as inflammation (swelling, redness). However, aspirin is not suitable for people who have had a stomach ulcer or aspirin allergy.

Nonsteroidal anti-inflammatory drugs (NSAIDs) relieve pain as well as inflammation. There are a wide variety of both OTC and prescription NSAIDs to choose from, including:

• Diclofenac (Cataflam®, Voltaren®)
• Diflunisal (Dolobid®)
• Etodolac (Lodine®)
• Flurbiprofen (Ansaid®)
• Ibuprofen (Advil®, Motrin®)
• Indomethacin (Indocin®), Tolmetin (Tolectin®)
• Ketoprofen (Actron®,
• Meclofenamate (Meclomen®)
• Nabumetone (Relafen®)
• Naproxen (Aleve®, Anaprox®, Naprelan®, Naprosyn®)
• Orudis®, Oruvail®)
• Oxaprozin (Daypro®)
• Phenylbutazone
• Piroxicam (Feldene®)
• Salsalate (Disalcid®)
• Sulindac (Clinoril®)

Unfortunately, NSAIDs have been characterized as having a ‘double-edged sword,’ since gastrointestinal (GI) complaints – which range from stomach upset to ulceration and bleeding – are common side effects of these medicines.

• Such complaints sometimes can be controlled by taking the NSAID with food or by using antacids between meals.
• However, if GI problems are more than mild or are long-lasting, the physician may prescribe an NSAID that causes fewer GI side effects (for example, salsalate).
• Note that NSAIDs also can cause kidney damage, worsen blood pressure (with salt and fluid retention), and contribute to bleeding by affecting the platelets (clotting elements in the blood).

NSAID partners may be prescribed by a physician to lessen the side effects of NSAIDs. These include:

• Antacids
• The prostaglandin analoguemisoprostol (Cytotec®)
• H2-blockers such as ranitidine (Zantac®)
• Proton-pump inhibitors such as omeprazole (Prilosec®).

The proton pump inhibitors and misoprostol decrease the risk of ulcers, while the H2-blockers only help symptoms.

Cox II inhibitors are reasonably new medications that reduce the pain of osteoarthritis and also reduce the chance of developing ulcers, and so partially preventing the GI complaints associated with NSAIDs. These medicines, which are available by prescription only, include:

• Celecoxib (Celebrex®)
• Rofecoxib (Vioxx®)

Vioxx was withdrawn from the market during September 2004 due to side effects that had not previously been anticipated at the time of its release just a few years earlier. These side effects include the increased risk of developing a stroke.

Muscle relaxants sometimes are prescribed for osteoarthritis if muscle spasms contribute to a person’s discomfort. These include:

• Cyclobenzaprine (Flexeril®)
• Carisoprodol (Soma®)
• Methocarbamol (Robaxin®)

Other prescription drugs, including sleep medications and antidepressants, may be beneficial in certain individuals.

Over-the-counter (OTC) creams, rubs, and sprays can be applied topically (to the skin) for temporary relief of pain in a sore muscle or joint. These products work in various ways, depending upon their ingredients. Some products contain:

• Salicylates (aspirin-related compounds that relieve pain)
• Skin irritants (chemicals that cause cold, warm, or other sensations, thereby reducing feelings of pain)
• Capsaicin (a “hot” substance found in chili peppers which blocks pain signals to the brain)

Most creams, such as those containing capsaicin, must be reapplied three to four times daily and may require two to four weeks of use before effects are noticeable.

Most programs that include medications emphasize the importance of:

• Sticking with a schedule for medication
• Taking only the medication prescribed or recommended by a physician
• Consulting a physician before taking any new medications, including over-the-counter (OTC) products. Some OTC products have the same ingredients as prescription medications, so one runs the risk of overdose unless all medications are discussed with a physician

Other Pain Relief Options

• Transcutaneous electrical nerve stimulation (TENS) is a technique that directs small pulses of electricity to specific nerves. The aim is to reduce the sensitivity of nerve endings in the spinal cord, thereby closing the pain “gates.” Although TENS is not effective in all arthritis sufferers, some people find it to be a practical means of pain control. The procedure, which produces a tingling sensation at the site of the electrical pads, has few side effects (some people have reported allergic reactions to the jelly used to apply the pads). TENS instruction usually is provided by a physiotherapist, who can explain how to position the pads, select the correct electrical frequency and pulse strength, and time how long the treatment should last.
• Acupuncture may provide short-term relief of pain. If performed properly with sterile needles, acupuncture can do no harm. Acupuncture therapy is believed to work by stimulating the body’s own pain-relieving hormones. However, acupuncture cannot “cure” arthritis; its effects are temporary.
• Therapeutic massage
• Yoga
• Physical therapy

Stress Control

Emotional stress sometimes causes arthritic symptoms to worsen. Repeated daily stresses – such as money problems, traffic jams, or shopping difficulties – may increase joint discomfort.

Although emotional anxiety does not appear to be as important a factor in osteoarthritis as it is in rheumatoid arthritis, osteoarthritic pain may develop after stressful life events, like the loss of a loved one or separation from a spouse.

Arthritis itself is a source of stress.

• Individuals may feel trapped in a vicious cycle in which arthritic pain causes stress and stress causes more pain.
• In addition, they may have a low self esteem and feel a loss of control because of arthritis-related concerns such as pharmaceutical bills, side effects from medicines, limited mobility, or unwelcome physical changes.

Stress management techniques are especially significant, because they can help people to regain a sense of control while relieving their arthritic pain.

Proven techniques for stress management include:

• Muscle relaxation
• Controlled breathing
• Biofeedback
• Self-hypnosis
• Time management
• Social support
• Assertiveness training
• Coping skills training

Injections Into The Joint

Corticosteroids, such as prednisone, are medications that lessen inflammation, swelling, and pain. These medicines generally are not used for OA; however, the direct injection of corticosteroids into an inflamed joint can markedly reduce the swelling of soft tissues and relieve pain.

• Unfortunately, corticosteroids can cause adverse side effects (such as joint degradation) when injected indiscriminately over long periods of time directly into a joint. Therefore, they should be used only to treat occasional bouts of joint pain and swelling in OA, particularly in younger people.
• A single injection may be sufficient to relieve OA for several months. The effect lasts for different amounts of time in different people.
• They don’t work for everyone

Injectable hyaluronic acid – which currently is marketed under the brand names Hyalgan® and Synvisc® – is a new FDA-approved treatment for osteoarthritis of the knee. This form of therapy, known as “visco-supplementation,” involves the injection of hyaluronic acid into the joint once a week for three to five weeks, depending on the product brand.

• Hyaluronic acid is a lubricating substance that is found in the normal joint fluid. If, as in osteoarthritis of the knee, inflammation breaks down hyaluronic acid within the joint, then lubrication is lost.
• Hyaluronic acid injection does not cause the side effects of most oral pain relievers. Therefore it is suitable for people who still suffer discomfort after being treated by pain medication, exercise, or physical therapy.
• Hyaluronic acid injection may provide relief for up to 12 months, but there is no indication that the treatment alters the progression of arthritis.
• Ongoing studies are investigating whether this method is effective for the shoulders and hips, but, to date, there is little information on the long-term effects of hyaluronic acid injection.
• In general, the treatment is well tolerated, and allergic reactions are rare.

Surgery

Although recent advances in joint surgery have improved the lives of millions of people throughout the world, surgery is NOT the first line of treatment for osteoarthritis.

Before surgery is ever contemplated, simpler treatments must be tried. Moreover, most surgeons prefer not to perform operative procedures in younger people unless their quality of life is severely affected by arthritis.

When surgery is necessary, it is performed by an orthopedic surgeon – a specialist in surgery of the bones and joints.

There are four main types of surgery available:

1. Fusion (permanent joining of the bones in a joint, preventing motion)
2. Osteotomy (realigning the joint)
3. “Scoping” the joint (washing out the joint)
4. Joint replacement (replacement of a damaged joint with an artificial joint)

1. Fusion of the joint, otherwise known as arthrodesis is a procedure in which the surfaces of the joint are removed and the bone ends are united. This provides pain relief and stability, but the joint cannot bend.

   Lack of mobility is a serious disadvantage of this procedure. Nevertheless, this is the preferred surgery for some younger individuals who have a single involved joint. Mobility in the other joints often will compensate for the loss of movement in the fused joint. The joints most commonly fused are smaller joints, such as those in the toes or fingers.

   Younger people with severe arthritis of the hip or knee in whom fusion was once offered, are now considered for total joint replacement (see below), though depending on the individual, a fusion may sometimes be preferable

2. Osteotomy is an operation in which the surgeon cuts the bone below the affected joint, realigns it, and resets it in a better position. This procedure changes and improves the contact between the remaining healthy areas of cartilage in the joint. Afterwards, the painful areas do not rub against each other.

   Osteotomy provides pain relief and leaves the joint mobile; however, it can only be performed in a joint that is not already stiff. Osteotomy usually is reserved for joints with uneven damage. It is not performed frequently, although the procedure sometimes is a good choice for younger arthritis sufferers, since it can prevent further joint damage and postpone the need for joint replacement surgery. (For example, osteotomy of the tibia [shinbone] is performed to correct curvature and weight-bearing in the lower leg of adults with OA of the knee.)

3. “Scoping” the joint is an expression used to describe arthroscopy – the examination of the inside of a joint using a device equipped with a tiny video camera. By means of arthroscopy, the physician can look for damaged tissue directly within the joint.

   A small incision is made through the skin alongside the affected joint. Then, microsurgical tools are used to remove areas of cartilage or cartilage fragments that are causing irritation and thoroughly wash out the joint. Arthroscopy is an outpatient procedure and does not require an overnight stay in the hospital.

   Joint “scoping” may provide temporary relief from symptoms – especially those caused by cartilage tears or particles; however, it does not stop the progression of osteoarthritis. It may help for a month in some, six months or much longer in others, and sometimes not at all.

4. Total joint replacement involves the complete removal of the painful joint, which is exchanged for a man-made appliance. The artificial joint can be fashioned from a combination of materials, including stainless steel, Vitallium™ (a cobalt-chromium alloy), titanium, and high-density polyethylene plastic. Silicone rubber occasionally is used for joint replacements (hand, base of the thumb), if the surgeon elects not to fuse the joint.

   The hip and knee have shown the greatest successes of all joint replacement surgery. Over 90 percent of people are free of pain and have good mobility following hip replacement surgery for osteoarthritis. Other joints that are less commonly replaced are the shoulder and elbow.

   Unfortunately, joint replacements tend to last only 10 to 20 years. But another replacement generally can be performed, if needed. This repeat surgery is called a revision.

   For further information about hip replacement, go to Total Hip Replacement.

   For further information about knee replacement, go to Total Knee Replacement.