What are osteoarthritis treatment options?
Aside from weight reduction and avoiding activities that exert excessive stress on the joint cartilage, there is no specific medical treatment to halt cartilage degeneration or to repair damaged cartilage in osteoarthritis. The goal of treatment in osteoarthritis is to reduce joint pain and inflammation while improving and maintaining joint function. Some patients with osteoarthritis have minimal or no pain and may not need treatment. Others may benefit from conservative measures such as rest, exercise, diet control with weight loss, physical therapy and/or occupational therapy, and mechanical support devices, such as knee braces. These measures are particularly important when large, weight-bearing joints are involved, such as the hips or knees. In fact, even modest weight reduction can help to decrease symptoms of osteoarthritis of the large joints, such as the knees and hips. Medications are used to complement the physical measures described above. Medication may be used topically, taken orally, or injected into the joints to decrease joint inflammation and pain. When conservative measures fail to control pain and improve joint function, surgery can be considered.
Resting sore joints decreases stress on the joints and relieves pain and swelling. Patients are asked to simply decrease the intensity and/or frequency of the activities that consistently cause joint pain.
Physical activity usually does not aggravate osteoarthritis when performed at levels that do not cause joint pain. Exercise is helpful for relief of symptoms of osteoarthritis in several ways, including strengthening the muscular support around the joints. It also prevents the joints from "freezing up" and improves and maintains joint mobility. Finally, it helps with weight reduction and promotes endurance. Applying local heat before and cold packs after exercise can help relieve pain and inflammation. Swimming is particularly well suited for patients with osteoarthritis because it allows patients to exercise with minimal impact stress to the joints. Other popular exercises include walking, stationary cycling, and light weight training.
Physical therapists can provide support devices, such as splints, canes, walkers, and braces. These medical devices can be helpful in reducing stress on the joints. Occupational therapy can assess the demands of daily activities and suggest additional devices that may help people at work or home. Finger splints can support individual joints of the fingers. Paraffin wax dips, warm water soaks, and nighttime cotton gloves can help ease hand symptoms. Spine symptoms can improve with a neck collar, lumbar corset, or a firm mattress, depending on what areas are involved.
In many patients with osteoarthritis, mild pain relievers such as aspirin and acetaminophen (Tylenol) may be sufficient treatment. Studies have shown that acetaminophen given in adequate doses can often be equally as effective as prescription anti-inflammatory medications in relieving pain in osteoarthritis of the knees. Since acetaminophen has fewer gastrointestinal side effects than NSAIDS (see below), especially among elderly people, acetaminophen is generally the preferred initial drug given to patients with osteoarthritis. Medicine to relax muscles in spasm might also be given temporarily. Pain-relieving creams applied to the skin over the joints can provide relief of minor arthritis pain. Examples include capsaicin (ArthriCare, Zostrix), salicin (Aspercreme), methyl salicylate (Ben-Gay, Icy Hot), and menthol (Flexall).
New topical treatments include an anti-inflammatory lotion, diclofenac (Voltaren Gel, Pennsaid) and diclofenac patch (Flector Patch), which are used for the relief of the pain of osteoarthritis.
Non-steroidal anti-inflammatory drugs (NSAIDs) are medications that are used to reduce pain and inflammation in the joints. Examples of NSAIDs include aspirin (Ecotrin), ibuprofen (Motrin), nabumetone (Relafen), and naproxen (Naprosyn). It is sometimes possible to use NSAIDs temporarily and then discontinue them for periods of time without recurrent symptoms, thereby decreasing the risk of side effects.
The most common side effects of NSAIDs involve gastrointestinal distress, such as stomach upset, cramping diarrhea, ulcers, and even bleeding. The risk of these and other side effects increases in the elderly. Newer NSAIDs called COX-2 inhibitors have been designed that have less toxicity to the stomach and bowels. Because osteoarthritis symptoms vary and can be intermittent, these medicines might be given only when joint pains occur or prior to activities that have traditionally brought on symptoms.
Some studies, but not all, have suggested that alternative treatment with the food supplements glucosamine and chondroitin can relieve symptoms of pain and stiffness for some people with osteoarthritis. These supplements are available in pharmacies and health-food stores without a prescription, although there is no certainty about the purity of the products or the dose of the active ingredients because they are not monitored by the U.S. FDA. The National Institutes of Health studied glucosamine in the treatment of the pain of osteoarthritis. Their initial research demonstrated only a minor benefit in relieving pain for those with the most severe osteoarthritis, and in most patients, there was no benefit greater than that from placebo pills. Further studies, it is hoped, will clarify many issues regarding dosing, safety, and effectiveness of different formulations of glucosamine for osteoarthritis. Patients taking blood thinners should be careful when taking chondroitin as it can increase the blood thinning and cause excessive bleeding. Fish-oil supplements have been shown to have some anti-inflammatory properties, and increasing the dietary fish intake and/or taking fish-oil capsules (omega-3 capsules) can sometimes reduce the inflammation of arthritis.
While oral cortisone is generally not used in treating osteoarthritis, when injected directly into the inflamed joints, it can rapidly decrease pain and restore function. Since repetitive cortisone injections can be harmful to the tissues and bones, they are reserved for patients with more pronounced symptoms.
For persisting pain of severe osteoarthritis of the knee that does not respond to weight reduction, exercise, or medications, a series of injections of hyaluronic acid (Synvisc, Hyalgan, Orthovisc, Supartz, Euflexxa) into the joint can sometimes be helpful, especially if surgery is not being considered. These products seem to work by temporarily restoring the thickness of the joint fluid, allowing better joint lubrication and impact capability, and perhaps by directly affecting pain receptors.
Surgery is generally reserved for those patients with osteoarthritis that is particularly severe and unresponsive to the conservative treatments. Arthroscopy, discussed above, can be helpful when cartilage tears are suspected. Osteotomy is a bone-removal procedure that can help realign some of the deformity in selected patients, usually those with certain forms of knee disease. In some cases, severely degenerated joints are best treated by fusion (arthrodesis) or replacement with an artificial joint (arthroplasty). Total hip and total knee replacements are now commonly performed in community hospitals throughout the United States. These can bring dramatic pain relief and improved function.