Treatment of Osteoarthritis

Treatment of osteoarthritis can help a patient to alleviate the pain, increase the ability of movement, and perform daily activities. The treatment plan may include medication, weight control, physical therapy, and especially the patient education about the disease. If failed, joint replacement surgery will help patient to relieve the symptoms and gain better movement. Treatment of osteoarthritis also depends on which joint(s) affected, severity of the disease and especially the patient’s chronic disease (s) which contributes to the selection of the type of medications and physical therapy. The changes of personality and everyday movement which may associate with the patient’s occupation are also important in the planning of treatment for the patient.

Physical therapy
Osteoarthritis results in the decrease of joint movement which in turn decreases daily activities. Physical therapists and occupational therapists play an important role in the treatment of osteoarthritis in order to relieve the joint ache/pain and increase joint movement. Benefits of physical therapy include
  • Strengthening of muscles surrounding the joint and increase of joint movement.
  • Introduction of assistive devices for the movement such as canes, crutches, walkers, etc.
  • Provision of education in heat and cold therapy in order to reduce aches/pain
  • Assistance in wearing and adjusting devices to fit the joint properly and appropriately.
  • Provision of education in the proper use of joints, in order to prevent joint trauma.
  • Provision of recommendation for the proper and appropriate selection of patient shoes.
Joint stretching
Slow and gentle joint stretching will help prevent stiffness and ease joint movement, particularly in the morning time when joint stiffness usually takes place. Joint stretching may be performed on own at home with instructions from the physical therapist or in recreational style such as yoga or Chinese-boxing dance.
Aerobic exercise
Aerobic exercise is an important part of osteoarthritis treatment. It helps relieve the pain, enhance the strength of the muscles surrounding the joint, reduce body weight and generally improve joint function. Water exercise such as water walking or swimming makes use of water to support the body weight which helps reduce the loading to the joint while enhancing the strength of the muscles surrounding the joint. Walking is also another good exercise but running that puts weight on knee joints and ankles may cause the pain in the knee joints or ankles to get worse.
Weight control
Weight reduction helps decrease the development of osteoarthritis and delay the progression of the affected joint(s), particularly the weight-bearing joints such as spine, hips, knees and ankles. Weight reduction also helps decrease blood pressure and blood lipids and improve general health of the body. The principle of the weight reduction is to decrease the calorie content of foods in combination with the exercise. The patient should always consult with a physician before using any weight loss medication and discuss with a physician to get informed about your appropriate body weight.
Patient education
Understanding of osteoarthritis is a key to the successful treatment. Although it may not completely cure the disease, but you and your physician can assist in controlling the disease. As for the patient, he (she) can help improve the treatment if he (she)
  • Learns about osteoarthritis as much as possible through discussion with his (her) physician.
  • Learns to accept that the ability to perform some routine activities may be decreased and, at the same time, learns with intention to find out the routine activities that still can be performed with happiness, joy and without worsening the affected joint(s).
  • Talks to friends and family members about what osteoarthritis feels like for him (her) so that they can understand about it.
  • Learns to have an optimistic view of the world.
Most patients are able to control the symptoms of osteoarthritis, by doing exercise, physical therapy or various procedures mentioned above, while some patients require medication to help alleviate the pain. Some medications need to be taken continuously every day while some are taken only when the symptoms are severe. The physician will advise the recommended type of drugs and the frequency of administration.
Most drugs used for osteoarthritis treatment will be mentioned here. However, there are many other drugs and procedures under clinical trials and studies which will not be referred to.

The pain reliever, which is considered cheap and safe and has shown to benefit the treatment of pain in osteoarthritis patients, is acetaminophen (paracetamol). Its effectiveness in pain relief is moderate, but it will not help reduce swelling and inflammation possibly experienced by osteoarthritis patients as it does in nonsteroidal anti-inflammatory drugs (NSAIDs) group. However, acetaminophen is considered cheaper and safer than nonsteroidal anti-inflammatory drugs (NSAIDs) group and should be used as first line treatment to relieve aches/pain prior to other more-expensive and more-side-effects drugs. The dose in adults with normal liver function is 1-2 tablets every 4-6 hours or about 4 grams daily.
Some patients may require narcotic drugs that possess higher efficacy in relieving the pain. The drugs in this group include tramadol, codeine which although are more active in killing pain but are not active in reducing inflammation. These drugs may also cause nausea, vomiting, constipation, and especially drug addiction.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs (abbreviated from Nonsteroidal Anti-Inflammatory Drugs) help reduce the ache/pain, stiffness, swelling, inflammation of the joint. This group of medication includes a wide variety of drugs such as ibuprofen, naproxen, diclofenac (Voltaren®), etc. The drugs in this group are active in reducing production of prostaglandin which is the substance that causes inflammation and ache/pain. However, prostaglandin can also be found in the stomach and kidney with its role of supporting the functions of said organs. Therefore the main side effects of drug administration in this group are the developments of stomach inflammation and ulcers, and impaired renal function. These drugs should not be used in patients with a medical history of stomach ulcers, especially the patients with untreated stomach or intestinal bleeding. All drugs in nonsteroidal anti-inflammatory drugs (NSAIDs) group as well as cyclooxygenase-2 (COX-2) inhibitors (see below) are prohibited in patients with renal problems as they can cause renal failure. When taking nonsteroidal anti-inflammatory drugs (NSAIDs), patients with a history of stomach inflammation or having abdominal pain will usually be combinedly prescribed with antacids, or drugs in acetaminophen or tramadol group, or nonacetylated drugs (such as salsalate) which are considered safer for the stomach and renal system.
The new nonsteroidal anti-inflammatory drugs (NSAIDs) called cyclooxygenase-2 (COX-2) inhibitors such as celecoxib (Celebrex®), etoricoxib (Arcoxia®), etc. exert their actions by reducing prostaglandins at the inflamed site without reducing prostaglandins in the stomach. Therefore, they are quite safe for patients with a history of ulcerative stomach inflammation but still affect the renal functional impairment in patients with renal dysfunction as same as other nonsteroidal anti-inflammatory drugs (NSAIDs). So they should not be used to treat patients with renal dysfunction.
Cyclooxygenase-2 (COX-2) inhibitors are quite expensive, however they are convenient with only once- or twice-daily dosing. The important thing that has to be mentioned is the suggestion not to use two nonsteroidal anti-inflammatory drugs (NSAIDs) or nonsteroidal anti-inflammatory drugs (NSAIDs) plus cyclooxygenase-2 (COX-2) inhibitors together as they have similar mechanism of action. Combined use of two drugs not only is useless and a waste of money, but also increases more side effects.

Steroid injection into joint
Steroids are anti-inflammatory drugs which can be injected directly into an affected joint to reduce inflammation and ache/pain in patients with osteoarthritis. Steroid injection into joints will usually be performed by an orthopedist or orthopedic surgeon no more than 3-4 times per year as frequent steroid injections into the weight-bearing joints such as hip joints, knee joints or ankles may cause degeneration of cartilage as well.
Hyaluronic acid or hyaluronan injection
Hyaluronic acid or hyaluronan is a component of joint nourishing fluid. Patient with osteoarthritis will have less hyaluronic acid content than normal people due to the depletion caused by inflammation. Hyaluronic acid injection (hyaluronic or Hylan G-F 20) once a week for 2-5 weeks based on the type used will help reduce the ache/pain and remain effective for months in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) but with uncontrolled condition or in patients unable to take nonsteroidal anti-inflammatory drugs (NSAIDs). Drugs in this group are quite expensive and may cause side effects such as pain, swelling at the injection site.
Topical analgesics or analgesic sprays for joint
Topical analgesics or analgesic sprays contain nonsteroidal anti-inflammatory drugs (NSAIDs), Salicylates, skin irritants and local anesthetics which help relieve pain in the joint. Drugs in this group help reduce the pain by increasing blood circulation of the skin around the joint which in turn increases the skin temperature, resulting in the relief of pain. Skin irritants help stimulate nerve endings in the skin to cause feelings of cold or warmth which distract the pain sensation, resulting in the relief of pain.
The irritant, capsaicin, will help decrease a substance in the nerve endings called “substance P” which results in the relief of pain. Application of capsaicin in the early stage will cause a burning sensation which usually decreases and goes away with time.
Eating a healthy, well balanced diet that does not cause obesity plays an important role in the treatment for osteoarthritis patients. There is no prohibition in a diet for these patients. Supplements like glucosamine and chondroitin sulfate have been used for osteoarthritis treatment. These two substances are components of the substances found around the cells of cartilage. Studies in patients found that these two substances relieved the ache/pain moderately and might decrease the degeneration of cartilage. However, it has not been clearly known how the substances work and, after taken, how much of the absorbed content has been taken up by the joints. Current information reveals the decrease of ache/pain in knee joints but no clear evidence of the symptom decrease in the joints of the hips, spine and fingers. The studies of the long-term efficacy of these two substances are still going on and required to verify their benefits found in the previous studies.
Most osteoarthritis patients do not require surgery to control the condition while only a few patients may need surgery to control the joint ache/pain which is uncontrollable by oral medication and injection into the joint, or if the joint is severely damaged to dysfunctional condition. The surgery may be performed using arthroscopy in order to remove the cartilage fragments which are degraded and broken off in the joint, smooth the cartilage surface, and repair the torn ligaments. Surgery may be in the form of osteotomy in order to allow the weight loading on the healthy portion of cartilage. If the joint is under a very bad condition, joint replacement surgery may help alleviate the ache/pain and improve the joint function. These surgeries are costly, require a period of convalescence, and have a limited service life depending on the type of artificial joint used with potential infection of the artificial joint in the future. Cartilage transplant, from the area of good cartilage to the area of degenerative cartilage in the same patient, has been used to treat young patients with joint trauma. However, this treatment is only available in certain leading medical centers.
Acupuncture has been used medically for many diseases in order to treat the ache/pain as well as osteoarthritis. Results from the studies have shown both beneficial and non-beneficial effects. Further study is still required to determine whether acupuncture is beneficial for osteoarthritis as well as the information gathering to ensure the acupuncturist using clean and safe devices, certified for professional practice and possessing clinical experiences.

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