Osteoarthritis Treatments

Treatment of OA consists of exercise, manual therapy, lifestyle modification, medication and other interventions to alleviate pain.

Lifestyle modification

No matter the severity or location of OA, conservative measures such as weight control, appropriate rest, exercise, and the use of mechanical support devices can be beneficial. In OA of the knees, knee braces can be helpful. A cane, or a walker can reduce pressure on involved leg joints which can be helpful for walking and support. Regular exercise such as walking or swimming, or other low impact activities are encouraged. Applying local heat before, and/or cold packs after exercise, can help relieve pain, as can relaxation techniques. Weight loss can relieve joint stress and may delay progression although research supporting this is equivocal.

Physical measures

Proper advice and guidance by health care providers such as chiropractors, physical therapists, occupational therapists, and medical doctors is important in OA management, enabling people with this condition to improve their quality of life.

Functional, gait, and balance training has been recommended to address impairments of proprioception, balance, and strength in individuals with lower extremity arthritis. These deficits can contribute to higher fall risk in older individuals.

Patient education

Patient education has been shown to be helpful in the self-management of patients with arthritis in decreasing pain, improving function, reducing stiffness and fatigue, and reducing medical usage. A meta-analysis has shown patient education can provide on average 20% more pain relief when compared to NSAIDs alone in patients with hip OA or rheumatoid arthritis.

Exercise

Moderate exercise leads to improved functioning and decreased pain in people with osteoarthritis of the knee.

Adequate joint motion and elasticity of periarticular tissues are necessary for cartilage nutrition and health, protection of joint structures from damaging impact loads, function, and comfort in daily activities. Exercise to regain or maintain motion and flexibility by low-intensity, controlled movements that do not cause increased pain. Muscle weakness around an osteoarthritic joint is a common finding. Progressive resistive/strengthening exercises load muscles in a graduated manner to allow for strengthening while limiting tissue injury.

Splinting of the thumb for OA of the base of the thumb leads to improvements after one year.

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.

Medication

Paracetamol

Paracetamol (Tylenol/acetaminophen), is commonly used to treat the pain from OA, and was recommended in 16 of 16 guidelines evaluated in a 2007 review of existing guidelines. A randomized controlled trial comparing paracetamol with ibuprofen in x-ray-proven mild to moderate osteoarthritis of the hip or knee found equal benefit. However, paracetamol at a dose of 4 grams per day can increase liver function tests. In 2006, however, a Cochrane review found a small benefit (effect size of 0.13) from paracetamol, suggesting questionable clinical significance. Most prominent drugs in the class include diclofenac, ibuprofen, naproxen and ketoprofen. High oral drug doses are often required. However, diclofenac has been found to cause damage to the articular cartilage. Even more importantly all systemic NSAIDs are rather taxing on the gastrointestinal tract, and may cause stomach upset, cramping, diarrhea, and peptic ulcer. Such systemic adverse side effects are normally not observed when using NSAIDs topically, that is, on the skin around the target area. The typically weak and/or short-lived therapeutic effect of such topical treatments may be improved by using the drug in more modern formulations, including or ketoprofen associated with the Transfersome carriers or diclofenac in DMSO solution.

Another type of NSAID, COX-2 selective inhibitors (such as celecoxib, and the withdrawn rofecoxib and valdecoxib) are often used but are no more effective than the other NSAIDs. These latter NSAIDs carry an elevated risk for cardiovascular disease, and some have now been withdrawn from the market.

Corticosteroids

Oral steroids are not recommended in the treatment of OA because of their modest benefit and high rate of adverse effects. However intra - articular corticosteroid temporarily improve symptoms as discussed below.

Opioid Analgesics

For moderate to severe pain a opioid analgesic such as morphine or codeine may be necessary.

Topical

There are several NSAIDs available for topical use (e.g. diclofenac, ibuprofen, and ketoprofen) with little, if any, systemic side-effects and at least some therapeutic effect. The more modern NSAID formulations for direct use, containing the drugs in an organic solution or the Transfersome carrier based gel, reportedly, are as effective as oral NSAIDs.

Creams and lotions, containing capsaicin, are effective in treating pain associated with OA if they are applied with sufficient frequency.

Injectable

A 2005 review of injections of hyaluronic acid, known as vicosupplementation, did not find that it led to clinical improvement in OA. A subsequent 2009 study found similar results.

Injection of glucocorticoids (such as hydrocortisone) leads to short term pain relief that may last between a few weeks and a few months.

Surgery

If the above management is ineffective, joint replacement surgery may be required. Individuals with very painful OA joints may require surgery such as fragment removal, repositioning bones, or fusing bone to increase stability and reduce pain. Arthroscopic surgical intervention for osteoarthritis of the knee has been found to be no better than placebo at relieving symptoms.

Alternative treatments

The majority of patients with arthritis have tried alternative treatments for their pain. Various studies have reported some benefit for many of these approaches, including acupuncture and some herbal supplements. However, the response rates tend to be low and there is concern about bias in many studies.

A 2007 review suggested acupuncture was an effective treatment for the pain and dysfunction associated with osteoarthritis of the knee
A 2007 review suggested acupuncture was useful for older patients with osteoarthritis of the knee and superior to waiting list or usual care groups but results were not clinically relevant for sham and actual acupuncture and were ascribed to a placebo effect.
A 2007 review found that electroacupuncture was associated with short-term relief of osteoarthritic knee pain better than placebo, but manual acupuncture was not, and the quality of the articles reviewed with small sample sizes may undermine the validity of conclusions.
A 2008 review suggested there was moderate quality evidence that acupuncture reduces pain for patients with osteoarthritis of the knee; the evidence for exercise and weight reduction was higher, and also improved physical function and self-reported disability respectively
A 2008 set of consensus recommendations produced by the Osteoarthritis Research Society International concluded that acupuncture may offer symptomatic benefits for osteoarthritis of the knee or hip
A 2008 review suggested that acupuncture provides short-term management of osteoarthritis-related knee pain. However, short-term treatment with acupuncture did not have long-term benefits.

Glucosamine/Chondroitin

There is controversy about glucosamine's effectiveness for OA of the knee. A 2005 review concluded that glucosamine may improve symptoms of OA and delay its progression. However, a subsequent large study suggests that glucosamine is not effective in treating OA of the knee, and a 2007 meta-analysis that included this trial states that glucosamine hydrochloride is not effective.. In addition, in vitro analysis of glucosamine has revealed that glucosamine inhibits cartilage cell characteristics . There is a "striking" difference between the results reported from trials involving glucosamine sulfate as compared to glucosamine hydrochloride, with glucosamine sulfate reporting an effect size of 0.44 compared to a 0.06 effect size from glucosamine hydrochloride; Osteoarthritis Research Society International recommends discontinuing glucosamine if no effect is observed after six months. There is concern that industry bias has affected the earlier trials, although a 2008 OARSI consensus review stated that this was "unsubstantiated". No adverse effects have been observed. The European League Against Rheumatism practice guidelines recommend glucosamine.

Chondroitin sulfate has also become a widely used dietary supplement for treatment of osteoarthritis, both in combination with glucosamine and by itself. A meta-analysis of randomized controlled trials found no benefit from chondroitin, although this meta-analysis included only 3 trials, one which had "an exceptionally high placebo response" and one which was published as only an abstract. A 2004 trial comparing SAMe and celecoxib found that during the first month the SAMe group reported more pain, but thereafter there was no significant difference between SAMe and celecoxib on reducing pain. The SAMe group reported somewhat fewer side-effects, consistent with a prior review.

Frankincense resin from ''Boswellia serrata'' trees—Indian frankincense is a traditional treatment for arthritis in Ayurvedic medicine.

Bromelain, protease enzymes extracted from the plant family Bromeliaceae (pineapple), blocks some proinflammatory metabolites.

Antioxidants, including vitamins C and E in both foods and supplements, provide pain relief from OA.

Ginger (rhizome) extract - has improved knee symptoms moderately.

Selenium deficiency has been correlated with a higher risk and severity of OA.

Vitamin B9 (folate) and B12 (cobalamin) taken in large doses has been thought to reduce OA hand pain in one very small, non-quantitative study of 25 people, the results of which are extremely vague at best.

Vitamin D deficiency has been reported in patients with OA, and supplementation with Vitamin D3 is recommended for pain relief.