Osteoarthritis and its Management

Many treatments are now available for osteoarthritis — education, behavioural changes, physical therapy, surgery and drugs

Osteoarthritis is the most common form of arthritis, affecting millions of people worldwide. It occurs when the protective cartilage on the ends of your bones wears down over time. Although osteoarthritis can damage any joint in your body, the disorder most commonly affects joints in your hands, knees, hips and spine. Osteoarthritis symptoms can usually be effectively managed, although the underlying process cannot be reversed. Staying active, maintaining a healthy weight and other treatments may slow progression of the disease and help improve pain and joint function.

SYMPTOMS

Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of osteoarthritis include:

Pain. Your joint may hurt during or after movement.

Tenderness. Your joint may feel tender when you apply light pressure to it.

Stiffness. Joint stiffness may be most noticeable when you wake up in the morning or after a period of inactivity.

Loss of flexibility. You may not be able to move your joint through its full range of motion.

Grating sensation. You may hear or feel a grating sensation when using the joint.

Bone spurs. These extra bits of bone, which feel like hard lumps, may form around the affected joint.

CAUSES

Osteoarthritis occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates. Cartilage is a firm, slippery tissue that permits nearly frictionless joint motion. In osteoarthritis, the slick surface of the cartilage becomes rough. Eventually, if the cartilage wears down completely, you may be left with bone rubbing on bone.

RISK FACTORS

Factors that may increase your risk of osteoarthritis include:

Older age. The risk of osteoarthritis increases with age.

Sex. Women are more likely to develop osteoarthritis, though it isn’t clear why.

Obesity. Carrying extra body weight contributes to osteoarthritis in several ways, and the more you weigh, the greater your risk. Increased weight puts added stress on weight-bearing joints, such as your hips and knees. In addition, fat tissue produces proteins that may cause harmful inflammation in and around your joints.

Joint injuries. Injuries, such as those that occur when playing sports or from an accident, may increase the risk of osteoarthritis. Even injuries that occurred many years ago and seemingly healed can increase your risk of osteoarthritis.

Certain occupations. If your job includes tasks that place repetitive stress on a particular joint, that joint may eventually develop osteoarthritis.

Genetics. Some people inherit a tendency to develop osteoarthritis.

Bone deformities. Some people are born with malformed joints or defective cartilage, which can increase the risk of osteoarthritis.

COMPLICATIONS

Osteoarthritis is a degenerative disease that worsens over time. Joint pain and stiffness may become severe enough to make daily tasks difficult. Some people are no longer able to work. When joint pain is this severe, doctors may suggest joint replacement surgery.

DIAGNOSIS

During the physical exam, your doctor will closely examine your affected joint, checking for tenderness, swelling or redness, and for range of motion in the joint. Your doctor may also recommend imaging and lab tests.

Imaging tests. Pictures of the affected joint can be obtained during imaging tests. Examples include:

X-rays. Cartilage doesn’t show up on X-ray images, but cartilage loss is revealed by a narrowing of the space between the bones in your joint. An X-ray may also show bone spurs around a joint. Some people may have X-ray evidence of osteoarthritis before they experience any symptoms.

Magnetic resonance imaging (MRI). An MRI uses radio waves and a strong magnetic field to produce detailed images of bone and soft tissues, including cartilage. An MRI isn’t commonly needed to diagnose osteoarthritis but may help provide more information in complex cases.

Lab tests. Analyzing your blood or joint fluid can help confirm the diagnosis.

Blood tests. Although there is no blood test for osteoarthritis, certain tests may help rule out other causes of joint pain, such as rheumatoid arthritis.

Joint fluid analysis. Your doctor may use a needle to draw fluid out of the affected joint. Examining and testing the fluid from your joint can determine if there’s inflammation and if your pain is caused by gout or an infection.

TREATMENT

Currently, the process underlying osteoarthritis cannot be reversed, but symptoms can usually be effectively managed with lifestyle changes, physical and other therapies, medications, and surgery. Exercising and achieving a healthy weight are generally the most important ways to treat osteoarthritis. Your doctor may also suggest:

Medications. Osteoarthritis symptoms, primarily pain, may be helped by certain medications, including:

Acetaminophen. Acetaminophen (Crocin, others) has been shown to be effective for people with osteoarthritis who have mild to moderate pain. Taking more than the recommended dosage of acetaminophen can cause liver damage.

Nonsteroidal anti-inflammatory drugs (NSAIDS). Over-the-counter NSAIDS, including ibuprofen and naproxen sodium, taken at the recommended doses, typically relieve osteoarthritis pain. Stronger NSAIDS, available by prescription, may also slightly reduce inflammation along with relieving pain. NSAIDS can cause stomach upset, cardiovascular problems, bleeding problems, and liver and kidney damage. Topical NSAIDS have fewer side effects and may relieve pain just as well.

Duloxetine. Normally used as an antidepressant, this medication is also approved to treat chronic pain, including osteoarthritis pain.

Physical Therapy. Physiotherapy helps you to keep your body moving and gives you the confidence to continue exercising. A physical therapist can be very effective and can work with you to create an individualized exercise program that will strengthen the muscles around your joint, increase your range of motion and reduce pain. Regular gentle exercise that you do on your own, such as swimming or walking, can be equally effective. Hydrotherapy can also be used to help ease pain and improve mobility in the joints.

Occupational therapy. An occupational therapist can help you dis- cover ways to do everyday tasks or do your job without putting extra stress on your already painful joint. For instance, a toothbrush with a large grip could make brushing your teeth easier if you have finger osteoarthritis. A bench in your shower could help relieve the pain of standing if you have knee osteoarthritis.

Tai chi, yoga, qigong. These movement therapies involve gentle exercises and stretches combined with deep breathing. Many people use them to reduce stress in their lives, and research suggests that they may reduce osteoarthritis pain and improve movement. When led by a knowledgeable instructor, these therapies are safe. Avoid those moves that cause pain in your joints.

SURGICAL AND OTHER PROCEDURES

If conservative treatments don’t help, you may want to consider other procedures:

Cortisone injections. Injections of corticosteroid medications may relieve pain in your joint. During this procedure your doctor numbs the area around your joint, then places a needle into the space within your joint and injects medication. The number of cortisone injections you can receive each year is generally limited to three or four injections, because the medication can worsen joint damage over time.

Lubrication injections. Injections of hyaluronic acid may offer pain relief by providing some cushioning in your knee, though some research suggests these injections offer no more relief than a placebo. Hyaluronic acid is similar to a component normally found in your joint fluid.

Realigning bones. If osteoarthritis has damaged one side of your knee more than the other, an osteotomy might be helpful. In a knee osteotomy, a surgeon cuts across the bone either above or below the knee, and then removes or adds a wedge of bone. This shifts your body weight away from the worn-out part of your knee.

Joint replacement. In joint replacement surgery (arthroplasty), your surgeon removes your damaged joint surfaces and replaces them with plastic and metal parts. Surgical risks include infections and blood clots. Artificial joints can wear out or come loose and may need to eventually be replaced.

Osteoarthritis of the knee is an extremely common cause of severe pain and disability in the community. It has been estimated that 7.5% of people over 55 years have some knee pain and disability associated with radiographic evidence of osteoarthritis and that approximately 2% have severe problems. Surgery, particularly TKR, is recommended for those with severe disease and can be of great value. However, recent reports have emphasized a number of problems associated with knee surgery. Many other treatments are now available for knee osteoarthritis, including education, behaviour change, physical intervention and drugs. Several management guidelines have been published over the last few years, most of which recommend a sequential approach, using simple measures first, such as education and advice about exercise, footwear and weight re-education, followed by the use of analgesics and physical therapy, reserving NSAIDS, intra articular interventions and surgery only for the most severe cases.

The likelihood of developing O.A increases significantly with age. Studies have shown knee O.A in men aged 60-64 is more commonly found in the right knee (23%) then in the left knee (16.3%) while its distribution seems to be more evenly balanced in women (right knee 24.2%, left knee 24.7%).

MANAGEMENT

Lifestyle changes can make a significant difference in osteoarthritis symptoms. Other home treatments also might help. Some things to try include:

Exercise. Exercise can increase your endurance and strengthen the muscles around your joint, making your joint more stable. Try walking, biking or swimming. If you feel new joint pain, stop. New pain that lasts for hours after you exercise probably means you’ve overdone it but doesn’t mean you have done any significant damage or that you should stop exercising. Simply resume a day or two later at a slightly lower level of intensity.

Lose weight. Obesity or even being somewhat overweight increases the stress on your weight-bearing joints, such as your knees and your hips. Even a small amount of weight loss can relieve some pressure and reduce your pain. Talk to a dietician about healthy ways to lose weight. Most people combine changes in their diets with increased exercise.

Use heat and cold to manage pain. Both heat and cold can relieve pain in your joint. Heat also relieves stiffness, and cold can relieve muscle spasms and pain. Capsaicin. Topical capsaicin — an active component in hot chili peppers — applied over an arthrititic joint may be an alternative for people who can’t take NSAIDS. It may not be noticeably helpful unless consistently applied three to four times a day for several weeks. Be sure to wash your hands well after applying capsaicin cream.

Apply over-the-counter pain creams. Creams and gels available at drugstores may provide temporary relief from osteoarthritis pain. Some creams numb the pain by creating a hot or cool sensation. Other creams contain medications, such as aspirin-like compounds, that are absorbed into your skin. Pain creams work best on joints that are close to the surface of your skin, such as your knees and fingers.

Braces or shoe inserts. Your doctor may recommend shoe inserts or other devices that can help reduce pain when you stand or walk. These devices can immobilize or support your joint to help take pressure off.

Knee taping. Strapping tape may help ease the pain of knee osteoarthritis. Ask a doctor or physical therapist to demonstrate how best to place the tape.

Use assistive devices. Assistive devices can make it easier to go about your day without stressing your painful joint. A cane may take weight off your knee or hip as you walk. Carry the cane in the hand opposite the leg that hurts.

Gripping and grabbing tools may make it easier to work in the kitchen if you have osteoarthritis in your fingers. Your doctor or occupational therapist may have ideas about what sorts of assistive devices may be helpful. Catalogues and medical supply stores may also be places to look for ideas.

Alternative medicine. Various complementary and alternative medicine may help with osteoarthritis symptoms. Treatments that have shown promise for osteoarthritis include:

Acupuncture. Some studies indicate that acupuncture can relieve pain and improve function in people who have knee osteoarthritis. During acupuncture, hair-thin needles are inserted into your skin at precise spots on your body.

Glucosamine and chondroitin. Studies have been mixed on these nutritional supplements. A few have found benefits for people with osteoarthritis, while most indicate that these supplements work no better than a placebo. Don’t use glucosamine if you’re allergic to shellfish. Glucosamine and chondroitin may interact with blood thinners such as warfarin and cause bleeding problems.

Avocado-soybean unsaponifiables. This nutritional supplement — a mixture of avocado and soybean oils — is widely used in Europe to treat knee and hip osteoarthritis. Borage seed oil, pine bark extract, evening primrose oil and rosehip are other herbal remedies that may slow down or prevent joint damage.

SAME. It is a chemical compound found naturally in your body. It stimulates the production of parts of cartilage, and may have antidepressant and painkilling properties. It is effective in reducing functional limitations and, to a lesser extent, pain in osteoarthritis. SAME also reduces body tenderness and depressive symptoms.

Indian frankincense and ginger. These Indian remedies can prevent the production of inflammatory substances in the joints, and can help in treating osteoarthritis of the knee.

Green-lipped mussels. It is a nutritional supplement taken from a type of mussel native to New Zealand. It contains omega-3 fatty acids, which have anti-inflammatory and joint-protecting properties. Fish body oil and fish liver oil are also rich in omega-3 fatty acids, which can help control your immune system and fight joint inflammation.

Coping and support. Lifestyle changes and certain treatments are key to managing pain and disability, but another major component to treatment is your own outlook on life. Your ability to cope despite pain and disability caused by osteoarthritis often determines how much of an impact osteoarthritis will have on your everyday life. Talk to your doctor if you’re feeling frustrated, because he or she may have ideas about how to cope or refer you to someone who can help. Although you may initially bring your concerns to your primary care doctor, he or she may refer you to a doctor who specializes in joint disorders (rheumatologist) or orthopedic surgery. You may want to write a list for him that includes: Detailed descriptions of your symptoms; Information about medical problems you’ve had; Information about the medical problems of your parents or siblings; All the prescription and over-the-counter medications and dietary supplements you take and the dosages. Questions you want to ask.

Cutting edge research gives us hope that one day people may gain freedom from the pain and distress caused by osteoarthritis. Researchers at Queen Mary University of London are embarking on a five-year study to discover more about the role of the molecule agrin in the cause and treatment of osteoarthritis. Meanwhile, another three-year study will explore if a protein found on nerves in and around our joints could be used to reduce pain and inflammation associated with osteoarthritis. Meanwhile, Danish researchers say they’ve found a link between many cases of low back pain and infection from bacteria that can be cured with a sustained course of simple antibiotics. Another study shows that treatment with the antibiotic doxycycline slowed the deterioration of joint tissue in women with osteoarthritis of the knee.. NOTE: The sole purpose of this article is to provide an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice should consult medical practitioner like an orthopaedic surgeon or physical therapist for exercise purpose and the initial rehabilitation should be done under the supervision of the physical therapist only.