Osteoarthritis medical therapy: Difference between revisions
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Revision as of 14:21, 21 June 2016
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Osteoarthritis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Osteoarthritis medical therapy On the Web |
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American Roentgen Ray Society Images of Osteoarthritis medical therapy |
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Risk calculators and risk factors for Osteoarthritis medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
Generally speaking, the process of clinically detectable osteoarthritis is irreversible, and typical treatment consists of medication or other interventions that can reduce the pain of OA and thereby improve the function of the joint.
Application of heat — often moist heat — eases inflammation and swelling in the joints, and can help improve circulation, which has a healing effect on the local area. Weight loss and muscle strengthening are also main stays of treatment.
Coping skills and lifestyle changes
No matter what the severity, or where the OA lies, conservative measures, such as weight control, appropriate rest and exercise, and the use of mechanical support devices are usually beneficial to sufferers. In the case of OA of the knees, knee braces, a cane, or a walker can be a helpful aid for walking and support. Regular exercise, if possible, in the form of walking or swimming, is encouraged. Applying local heat before, and cold packs after exercise, can help relieve pain and inflammation, as can relaxation techniques. Weight loss can relieve joint stress and may delay progression. Proper advice and guidance by a health care provider is important in OA management, enabling people with this condition to improve their quality of life.
In 2002, a randomized, blinded assessor trial was published showing a positive effect on hand function with patients who practiced home joint protection exercises (JPE). Grip strength, the primary outcome parameter, increased by 25% in the exercise group versus no improvement in the control group. Global hand function improved by 65% for those undertaking JPE. [1]
Dealing with chronic pain can be difficult and result in depression. Communicating with other patients and caregivers can be helpful, as can maintaining a positive attitude. People who take control of their treatment, communicate with their health care provider, and actively manage their arthritis experience can reduce pain and improve function.
Physical therapy
Some types of physical therapy may help according to a systematic review of trials.[2]
Dietary
Supplements which may be useful for treating OA include:
Glucosamine
A molecule derived from glucosamine is used by the body to make some of the components of cartilage and synovial fluid. Supplemental glucosamine may improve symptoms of OA and delay its progression.[3] However, a large study suggests that glucosamine is not effective in treating OA of the knee.[4] A subsequent meta-analysis that includes this trial concluded that glucosamine hydrochloride is not effective and that the effect of glucosamine sulfate is uncertain.[5]
Chondroitin
A meta-analysis of randomized controlled trials found no benefit from chondroitin.[6]
Other supplements
- Boswellia, an herbal supplement known in Aryuvedic medicine. It is widely available in health food stores and online.
- Antioxidants, including vitamins C and E in both foods and supplements, provide pain relief from OA. [7]
- Hydrolyzed collagen (hydrolysate) (a gelatin product) may also prove beneficial in the relief of OA symptoms, as substantiated in a German study by Beuker F. et al. and Seeligmuller et al. In their 6-month placebo-controlled study of 100 elderly patients, the verum group showed significant improvement in joint mobility.
- Methylsulfonylmethane (MSM): A small study by Kim et al. suggested that MSM significantly reduced pain and improved physical functioning in OA patients without major adverse events (Kim et al). The authors cautioned that although this short pilot study did not address the long-term safety and usefulness of MSM, they suggest that physicians should consider its use for certain osteoarthritis patients.
- S-adenosyl methionine: small scale studies have shown it to be as effective as NSAIDs in reducing pain, although it takes about four weeks for the effect to take place.
- Selenium deficiency has been correlated with a higher risk and severity of OA, therefore selenium supplementation may reduce this risk.[9]
- Vitamins B9 (folate) and B12 (cobalamin) taken in large doses significantly reduced OA hand pain, presumbably by reducing systemic inflammation.[10]
- Vitamin D deficiency has been reported in patients with OA, and supplementation with Vitamin D3 is recommended for pain relief.[11]
- Bone Morphogenetic Protein 6 (BMP-6) has recently been shown to have a functional role in the maintenance of joint integrity and is now being produced in an orally ingested form. [12]
Other nutritional changes shown to aid in the treatment of OA include decreasing saturated fat intake[13] and using a low energy diet to decrease body fat.[14] Lifestyle change may be needed for effective symptomatic relief, especially for knee OA.[15] Reducing sugar, processed foods, fatty foods and nightshade vegetables have helped many. According to Dr. John McDougall, a low fat vegetarian diet can reduce arthritis symptoms. A macrobiotic diet has been known to reduce symptoms as well.
Medications
Acetaminophen
A mild pain reliever may be sufficiently efficacious. Acetaminophen (tylenol/paracetamol), is commonly used to treat the pain from OA, although unlike NSAIDs, acetaminophen does not treat the inflammation. A randomized controlled trial comparing acetaminophen to ibuprofen in x-ray proven mild to moderate osteoarthritis of the hip or knee found that equal benefit.[16] However, acetaminophen at a dose of 4 grams per day can increase liver function tests.[17]
Non-steroidal anti-inflammatory drugs
In more severe cases, non-steroidal anti-inflammatory drugs (NSAID) may reduce both the pain and inflammation. These include medications such as diclofenac, ibuprofen and naproxen. High doses are often required. All NSAIDs act by inhibiting the formation of prostaglandins, which play a central role in inflammation and pain. However, these drugs are rather taxing on the gastrointestinal tract, and may cause stomach upset, cramping, diarrhoea, and peptic ulcer.
COX-2 selective inhibitors
Another type of NSAID, COX-2 selective inhibitors (such as celecoxib, and the withdrawn rofecoxib and valdecoxib) reduce this risk substantially. These latter NSAIDs carry an elevated risk for cardiovascular disease, and some have now been withdrawn from the market.
Corticosteroids
Intraarticular corticosteroids of the knee may reduce pain for one week after the injection.[18] However, a randomized controlled trial found "No additional benefit results from adding an intra-articular injection of 40 mg of corticosteroid before exercise in patients with painful OA of the knee."[19]
One trial that compared corticosteroid injections every three months to placebo for two years[20] found improvements in outcomes ranging from none to small for the WOMAC pain score[21]
Narcotics
For severe pain, narcotic pain relievers such as tramadol, and eventually opioids (hydrocodone, oxycodone or morphine) may be necessary; these should be reserved for very severe cases, and are rarely medically necessary for chronic pain.
Topical
"Topical treatments" are treatments designed for local application and action. Some NSAIDs are available for topical use (e.g. ibuprofen and diclofenac) and may improve symptoms without having systemic side-effects.
Creams and lotions, containing capsaicin, are effective in treating pain associated with OA if they are applied with sufficient frequency.
Severe pain in specific joints can be treated with local lidocaine injections or similar local anaesthetics, and glucocorticoids (such as hydrocortisone). Corticosteroids (cortisone and similar agents) may temporarily reduce the pain.
Prolotherapy
Prolotherapy (proliferative therapy); involves the injection of an irritant substance (such as dextrose) to create an acute inflammatory reaction or a proliferating substance (such as Sodium Morrhuate) to induce the body's natural wound healing cascade. It strengthens damaged tissues including ligaments, tendons and cartilage as part of this reaction. Most patients tolerate the injections without any difficulty, however they may be painful (like corticosteroids or hyaluronic acid) for a few days after wards. The only other significant risk is the rare possibility of infection.
Nerve Blocks
While most people dont think of nerve blocks when treating osteoarthritis, they can provide rather dramatic pain relief while also addressing the root cause of pain. Quite frequently muscles are in spasm when arthritis is present, in order to protect a diseased joint or as a result of mechanical problems that occur due to the arthritis. In fact, quite often a nerve irritation in the back will cause tight hamstrings. That in turn reduces joint space and causes abnormalities in joint mechanics. The result is a progression, or worsening of arthritis. The whole process can be reversed when such problems are present and addressed.
Hyaluronidase
Intraarticular viscosupplementation of the knee with hyaluronic acid is "associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events."[18]
References
- ↑ Stamm TA, Machold KP, Smolen JS; et al. (2002). "Joint protection and home hand exercises improve hand function in patients with hand osteoarthritis: a randomized controlled trial". Arthritis Rheum. 47 (1): 44–9. PMID 11932877.
- ↑ Wang SY, Olson-Kellogg B, Shamliyan TA, Choi JY, Ramakrishnan R, Kane RL (2012). "Physical therapy interventions for knee pain secondary to osteoarthritis: a systematic review". Ann Intern Med. 157 (9): 632–44. doi:10.7326/0003-4819-157-9-201211060-00007. PMID 23128863.
- ↑ Poolsup N, Suthisisang C, Channark P, Kittikulsuth W (2005). "Glucosamine long-term treatment and the progression of knee osteoarthritis: systematic review of randomized controlled trials". The Annals of pharmacotherapy. 39 (6): 1080–7. doi:10.1345/aph.1E576. PMID 15855241.
- ↑ McAlindon T, Formica M, LaValley M, Lehmer M, Kabbara K. Effectiveness of glucosamine for symptoms of knee osteoarthritis: Results from an internet-based randomized double-blind controlled trial. Am J Med 2004; 117:643-9. PMID 15501201.
- ↑ Vlad SC, Lavalley MP, McAlindon TE, Felson DT (2007). "Glucosamine for pain in osteoarthritis: Why do trial results differ?". 56 (7): 2267–2277. doi:10.1002/art.22728. PMID 17599746.
- ↑ Reichenbach S, Sterchi R, Scherer M; et al. (2007). "Meta-analysis: chondroitin for osteoarthritis of the knee or hip". Ann. Intern. Med. 146 (8): 580–90. PMID 17438317.
- ↑ McAlindon TE, Jacques P, Zhang Y, et al. Do antioxidant micronutrients protect against the development and progression of knee osteoarthritis? Arthritis Rheum 1996; 39:648-656
- ↑ Altman RD, Marcussen KC. Arthritis Rheum. 2001 Nov; 44(11):2531-8
- ↑ "UNC News release -- Study links low selenium levels with higher risk of osteoarthritis". Retrieved 2007-06-22.
- ↑ Flynn MA, Irvin W, Krause G. J Am Coll Nutr. 1994 Aug; 13(4):351-6.
- ↑ Arabelovic S, McAlindon TE. Curr Rheumatol Rep. 2005 Mar; 7(1):29-35.
- ↑ K. Bobacz, R. Gurber, A Soleiman, L. Erlacher, J.S. Smolen, and W.B. Grainger, Arthritis & Rheumatism 2003 Sep; 48(9) 2501
- ↑ Wilhelmi G. Z Rheumatol. 1993 May-Jun; 52(3):174-9. Vasishta VG et al, Rotational Field Magnetic Resonance (RFQMR) in treatment of osteoarthritis of the knee joint, Indian Journal of Aerospace Medicine, 48 (2), 2004; 1-7.
- ↑ Christensen R. Osteoarthritis Cartilage. 2005 Jan; 13(1):20-7.
- ↑ De Filippis L et al. Reumatismo. 2004 Jul-Sep; 56(3):169-84.
- ↑ Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI (1991). "Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee". N. Engl. J. Med. 325 (2): 87–91. PMID 2052056.
- ↑ Watkins PB, Kaplowitz N, Slattery JT; et al. (2006). "Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial". JAMA. 296 (1): 87–93. doi:10.1001/jama.296.1.87. PMID 16820551.
- ↑ 18.0 18.1 Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G (2006). "Intraarticular corticosteroid for treatment of osteoarthritis of the knee". Cochrane Database Syst Rev (2): CD005328. doi:10.1002/14651858.CD005328.pub2. PMID 16625636.
- ↑ Henriksen M, Christensen R, Klokker L, Bartholdy C, Bandak E, Ellegaard K; et al. (2015). "Evaluation of the benefit of corticosteroid injection before exercise therapy in patients with osteoarthritis of the knee: a randomized clinical trial". JAMA Intern Med. 175 (6): 923–30. doi:10.1001/jamainternmed.2015.0461. PMID 25822572.
- ↑ Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J; et al. (2003). "Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial". Arthritis Rheum. 48 (2): 370–7. doi:10.1002/art.10777. PMID 12571845.
- ↑ Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (1988). "Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee". J. Rheumatol. 15 (12): 1833–40. PMID 3068365. Unknown parameter
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