eMedicine Specialties > Physical Medicine and Rehabilitation > Arthritis & Connective Tissue Disorders

Osteoarthritis: Treatment & Medication

Author: Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine
Coauthor(s): Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Irim Ciolino, MD, Co-chief Resident, Department of Internal Medicine, New York Medical College/St Vincent's Catholic Medical Center
Contributor Information and Disclosures

Updated: Jul 16, 2009

Treatment

Rehabilitation Program

Physical Therapy

Lifestyle modification, particularly exercise and weight reduction, is a core component of the management of osteoarthritis (OA).^11,12 A program of physical therapy should emphasize the importance of strengthening all muscles that cross the given joint affected by OA.

Most research focuses on quadriceps strengthening in knee OA. Also important are stretching exercises, which increase range of motion. The importance of aerobic conditioning, particularly low-impact exercises (if OA affects weight-bearing joints), should be stressed. Swimming, especially aerobic aquatic programs through the Arthritis Foundation, can be helpful. Certain studies also indicate that a home exercise program for patients with OA of the knee provides an important benefit.

In a study of patients with knee osteoarthritis, Jan et al found that, in most respects, non – weight-bearing exercise was as therapeutically effective as weight-bearing exercise.¹³ After an 8-week exercise program, patients in the weight-bearing and non – weight-bearing groups showed equally significant improvements in function, walking speed, and muscle torque. However, patients in the weight-bearing group demonstrated greater improvement in position sense, which may help patients with complex walking tasks, such as walking on a spongy surface.

In terms of reducing osteoarthritis-related knee pain, Chaipinyo and Karoonsupcharoen found no significant difference between home-based strength training and home-based balance training.¹⁴ However, more improvement in knee-related quality of life was noted in the strength-training group than in the balance-training group.

In a review on patient adherence to exercise, Marks and Allegrante concluded that interventions to enhance self-efficacy, social support, and skills in the long-term monitoring of progress are necessary to foster exercise adherence in people with OA.¹⁵

Use of assistive devices for ambulation and for activities of daily living may be indicated. Braces and appropriate footwear may also be of some use. A cane can be used in the opposite hand for OA of the hip, and a cane in the hand of comfort may be helpful for OA of the knee. The patient can be taught joint-protection and energy conservation techniques. Other physical therapy modalities include electrotherapy and thermotherapy.

Related Medscape topic:
CME Therapeutic Exercise May Be Effective for Hip Osteoarthritis

Occupational Therapy

Evaluation of how well the patient performs his/her activities of daily living, as well as retraining of the patient, can be assisted by the occupational therapist. Emphasize joint-protection techniques. Hand splinting, especially of the first carpometacarpal joint, may be indicated.

Recreational Therapy

A home exercise program that incorporates all of the above treatment principles could be designed and implemented to help the patient with osteoarthritis retain mobility.

Medical Issues/Complications

Osteophyte formation in the spine can lead to radiculopathy and/or myelopathy. Osteophyte formation in the cervical spine near the vertebral arteries can lead to vertebral artery compression.

Surgical Intervention

Surgical intervention for osteoarthritis (OA) may be indicated. Types of procedures vary according to the site and the degree of involvement. The types of surgical interventions that can be employed include the following:

• Surgical interventions for OA of the knee
  • Arthroscopic lavage - Using a saline lavage to wash out the joint
  • Joint realignment (realignment osteotomy)
  • Joint fusion (arthrodesis) - Surgically fusing the joint to eliminate motion
  • Joint replacement (arthroplasty)
• Surgical interventions for OA of the hip
  • Joint realignment (realignment osteotomy)
  • Joint fusion (arthrodesis) - Surgically fusing the joint to eliminate motion
  • Joint replacement (arthroplasty)
    • Hip replacements generally are classified as either hemiarthroplasty (ie, replacement of the femoral side of the hip joint, while leaving the patient's acetabulum intact) or total hip arthroplasty (replacement of the femoral side of the hip joint and the acetabulum).
    • Further classification often involves specification of the specific hardware used (eg, unipolar prosthesis, bipolar prosthesis) and whether or not cement is used to hold the hardware in place.

Related eMedicine topics:
Acetabular Wear in Total Hip Arthroplasty
Complications of Total Knee Arthroplasty
Hip Replacement
Total Knee Arthroplasty
Unicompartmental Knee Arthroplasty

Related Medscape topic:
CME Arthroscopic Surgery May Not Be Helpful for Knee Osteoarthritis

Consultations

Consultation with an orthopedic surgeon may sometimes be needed. Rheumatology consultation is indicated if an alternative diagnosis (eg, rheumatoid arthritis) is suggested.

Related Medscape topic:
Resource Center Rheumatoid Arthritis

Other Treatment

Intra-articular steroid injections may provide pain relief and have an anti-inflammatory effect on the affected joint in osteoarthritis (OA). Such injections generally result in a clinically and statistically significant reduction in osteoarthritic knee pain as soon as 1 week after injection. The effect may last, on average, anywhere from 4-6 weeks per injection, but this benefit is unlikely to continue beyond that time frame.¹⁶ One randomized, placebo-controlled study confirmed the effectiveness of corticosteroid injection in the treatment of hip OA, with benefits often lasting up to 3 months.¹⁷ Some controversial evidence exists regarding frequent steroid injections and subsequent damage to cartilage (chondrodegeneration). Therefore, usually no more than 3 injections are recommended per year in any 1 osteoarthritic joint.

Intra-articular injection of sodium hyaluronate (ie, hyaluronic acid [HA], hyaluronan), also referred to as viscosupplementation, has been shown to be safe and effective for the symptomatic relief of knee OA. This topic has been reviewed in depth elsewhere.¹⁸ The largest meta-analysis of intra-articular HA injection, using 76 controlled clinical studies (and subsequently updated by the Cochrane Collaboration), concluded that this therapy is safe and effective in patients with knee OA.¹⁹

To date, the US Food and Drug Administration (FDA) has approved 5 intra-articular HAs for the treatment of pain associated with knee OA. These include naturally extracted, non–cross-linked sodium hyaluronate products (Hyalgan,²⁰ Supartz, Orthovisc, Euflexxa) and 1 cross-linked sodium hyaluronate product known as hylan G-F 20 (Synvisc). Euflexxa is the only product derived from a fermentation process (Streptococcus), while the source material for the other 4 products is chicken combs. At present, no distinct advantage or disadvantage has been associated with either source of HA production.

Some differences between the viscosupplements do exist in the FDA-approved prescribing information. For example, Hyalgan and Synvisc have labeling that establishes their safety for repeat treatment, while other products have the precautionary statement that "the safety and efficacy of repeat treatment has not been established."

The HA class in general has demonstrated a very favorable safety profile for the chronic pain management of knee OA, with the most common adverse event being injection site pain. While any intra-articular injection (all HA products and steroids) may elicit an inflammatory response and possible effusion, a clinically distinct acute inflammatory side effect (ie, severe acute inflammatory reaction [SAIR] or HA–associated intra-articular pseudosepsis) has been described. However, preclinical and clinical data provide compelling evidence that this reaction is limited only to the cross-linked hylan G-F 20 product and may have an immunologic mechanism of action. Molecular weight per se has not been found to correlate with efficacy (eg, higher or lower viscosity does not equate with better or worse clinical outcomes).

Interestingly, the duration of residence of an intra-articular injection (days) cannot explain the prolonged clinical benefit (months), and accordingly, subsequent biological mechanisms have also been proposed that may play an important role in the clinical benefit. The combination of quadriceps strengthening and HAs may have a synergistic effect on pain.²¹

In the United States, HAs are classified as medical devices rather than as drugs. Although the exact mechanisms of action through which they provide symptomatic relief are unknown, several possibilities exist, including direct binding to receptors (CD44 in particular) in the synovium and cartilage that can lead to several biologic activation pathways.

These mechanisms of action can include the increased endogenous production of hyaluronate and aggrecan by the joint, a mechanical barrier to the activation of nociceptors, the inhibition of pain mediators (eg, PGE, bradykinin), an anti-inflammatory effect (eg, inhibition of proinflammatory cytokine activity, inhibition of inflammatory cell function), a beneficial effect on immune cells, an antioxidant effect, and the restoration of the synovial fluid's physical characteristics (viscoelasticity). Viscosity can help to facilitate the cushioning and lubricating characteristics of the joint during slow movements, while elasticity blunts deforming forces (compression and resistance to shear forces) during rapid motions.

A study Waddell and colleagues hypothesized that hyaluronan inhibits interleukin-1beta–induced metalloproteinase production from osteoarthritic synovial tissue.²²

As reviewed by Goldberg and Buckwalter, preclinical support is available for most of the HAs, as well as clinical evidence (particularly for Hyalgan) using arthroscopy, microscopy, and blinded morphologic assessments and weight-bearing radiographs for assessing joint space narrowing.²³ Intra-articular HAs may also possibly be chondroprotective early in the development of OA. However, additional studies would seem to be warranted to further explore the ability of HAs to intervene in the disease processes associated with OA. Certainly, a single product with symptomatic and disease-modifying characteristics, even if only in some patient populations, would be a valuable option in the management of knee OA.

A pulsed electromagnetic field stimulation device (Bionicare) has also been FDA-approved for use in patients with knee OA. Pulsed electromagnetic field stimulation is believed to act at the level of hyaline cartilage by maintaining proteoglycan composition of chondrocytes via down-regulation of its turnover.²⁴ One published multicenter, double-blind, randomized, placebo controlled, 4-week trial (n = 78 knee OA) found improved pain and function in patients who were treated with the device.²⁵

Transcutaneous electrical nerve stimulation (TENS) may be another treatment option for pain relief, but so far, there is limited evidence suggesting that this method would be beneficial for some patients.²⁶

Acupuncture is becoming a more frequently utilized option in treating pain and physical dysfunction associated with osteoarthritis. There is some support in the literature for its use. For example, a review article of randomized, controlled trials found a significant decrease in pain after acupuncture in comparison with the amount of pain persisting after control treatments.²⁷

Related Medscape topics:
CME/CE Use of Corticosteroid Injections for Musculoskeletal Disease Reviewed
CME Viscosupplementation for Osteoarthritis of the Knee: Strategies to Improve Patient Outcomes

Medication

The American College of Rheumatology issued the following pharmacologic guidelines for the treatment of osteoarthritis of the hip and knee:

• Arthrocentesis with corticosteroid injection can be used only for knee OA if effusion is present.
• Up to 4 grams per day of acetaminophen can be administered. This is the preferred initial treatment for patients with OA.
• Topical anti-inflammatory medications or capsaicin can be administered only for knee OA.
• Low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) (ie, analgesic doses) or nonacetylated salicylates may be indicated.
• Administer full-dose NSAIDs with misoprostol if risk factors for upper gastrointestinal bleeding are present.
• Narcotic analgesic use may be indicated in cases of severe pain.

Other medications have been investigated in OA (eg, Tramadol, cyclooxygenase (COX)-2 inhibitors, dietary supplements). Many medications have been tried and are in use, but research on their effectiveness is lacking. Glucosamine and chondroitin sulfate, currently being studied by National Institutes of Health (NIH) in double-blind trials, have been used in Europe for many years. S-adenosylmethionine (SAM-e [pronounced "sammy"]) is a European supplement receiving a lot of attention in the United States. Chondroprotective drugs (ie, matrix metalloproteinase [MMP] inhibitors, growth factors) are being tested as disease-modifying drugs in the management of OA. Although a number of agents are currently under study, no agent has been shown to have a disease-modifying effect in humans.²⁸

Related Medscape topic:
CME/CE Chondroitin and Glucosamine: Hype or Hope for Osteoarthritis?

Simple analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have osteoarthritis.

Acetaminophen (Tylenol, Panadol, Feverall, Aspirin Free Anacin)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Topical analgesics

Topical analgesics are used for osteoarthritis involving relatively superficial joints, such as the knee joint and the joints of the hands. These agents are much less effective for deeper joints, such as the hip joint.

Capsaicin (Dolorac, Capsin, Zostrix)

Topical analgesic of choice in OA; capsaicin is derived from plants of the Solanaceae family. It may render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons. Capsaicin must be used for at least 2 weeks for the full effects to be appreciated. Salicylate creams and topical NSAIDs are available.

Nonsteroidal anti-inflammatory drugs

NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit COX activity and prostaglandin synthesis. Other mechanisms may exist as well, such as the inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Ibuprofen (Motrin, Advil, Nuprin, Rufen)

After the very early stages of OA, inflammation begins to play a role. Thus, medications with a combination of analgesic and anti-inflammatory properties become more desirable, at least in theory.

Meloxicam (Mobic)

To some extent, more selective for COX-2 receptors, compared with traditional NSAIDs. Meloxicam decreases the activity of COX, which in turn inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.

Cyclooxygenase-2 inhibitors

This class of medications can be particularly useful in the OA population, because patients in this group tend to be older and are therefore at increased risk for adverse GI effects due to NSAIDs. Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs.

Celecoxib (Celebrex)

Inhibits primarily COX-2. Considered an inducible isoenzyme, COX-2 is induced during pain and inflammatory stimuli. The inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, the COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.

Opioid analgesics

These agents are used in patients whose pain has not been controlled with weaker analgesic medications. They are a particularly reasonable choice in patients who do not want joint replacement surgery, are too medically ill for joint replacement, are not candidates for joint replacement for other reasons, or are trying to buy time for subsequent joint replacement surgery.

Oxycodone (OxyContin, Roxicodone)

Pure narcotic analgesics, such as oxycodone, might be the initial DOC. Eventually, this short-acting narcotic can be switched to a long-acting transdermal preparation, such as fentanyl (Duragesic patch).

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