For OA, treatment starts with the simplest and least risky interventions—ice packs, for example—and progresses, if necessary, to such therapies as joint injections and surgery. Treatment usually is simple in the early stages of the disease, and becomes more intense in later stages, especially if pain and disability become more severe. Sometimes combinations of treatments are the most effective. In general, treatment is focused on reducing pain and improving function. Currently, there are very few strategies proven to affect the progression of the disease, though research is ongoing
Every patient is different, and finding the right treatment or combination of treatments may take several months. This section includes information on nine treatment approaches:
- Topical therapy
- Supplements
- Complementary medicine
- Physical therapy
- Canes, braces, and orthotics
- Anti-inflammatory drugs
- Analgesic drugs
- Injections into the joint
- Surgery and replacement
Topical therapy
Some OA treatments can be applied directly on the skin, including two of the simplest: applying heat and cold. A bag of frozen peas or an ice pack placed over a painful joint lessens inflammation. The cold object should be wrapped up in a towel and should be used for no more than 20 minutes at one time, to avoid any risk of frostbite. By contrast, a hot water bottle or a warm bath will increase blood flow and loosen up a stiff joint. Some doctors feel that heat risks exacerbating inflammation, however, so a red and swollen joint may do better with ice.
A skin patch containing 5 percent lidocaine, a topical anesthetic, can reduce OA pain, a study has shown. Creams are also common remedies. Celecaine, a cream made of natural oils, lessened pain and improved function better than did a placebo in several scientific trials.
Supplements
One popular supplement, glucosamine-chondroitin, has been shown in several clinical trials to be both safe and modestly beneficial. Other studies have not shown beneficial results of these preparations. Both glucosamine and chondroitin are building blocks for cartilage and have effects in laboratory experiments on OA cells; however, whether they can slow down the destruction of cartilage in the body remains an area under research. There are lots of preparations on the market, however, and one lab analysis found that not all of them contain as much of these substances as they claim. Chondroitin was the ingredient most likely to come up short. It's best to purchase a recognized brand from a reputable store.
Methyl sulfonylmethane (MSM) is another supplement that people use to ease the pain of OA. It is an odorless and tasteless natural sulfur compound that is supposed to fight inflammation. MSM has not been through as much careful scientific testing as have glucosamine and chondroitin however, so there are more doubts about its effectiveness.
Patients using supplements should inform their primary care physician, because some of these supplements have ingredients that might interact badly with standard drugs or have other undesirable effects.
Complementary medicine
Nontraditional, or complementary, medicine has been gaining in popularity. Studies of its effectiveness as a treatment for OA, however, have left many doctors skeptical.
Some people have found pain relief using acupuncture (the use of fine needles inserted at specific points on the skin). Preliminary research shows that acupuncture may be a useful component in an osteoarthritis treatment plan for some patients. Other studies have demonstrated that yoga may also help to relieve arthritis pain.
Doctors are a lot more dubious about two folk remedies: magnets and copper bracelets. While some studies have shown that magnets of certain strengths may relieve pain, the relief is minimal and only for a short time, and the magnets can be expensive. As for copper bracelets, there is no reliable research demonstrating any benefit to OA patients.
Patients trying complementary techniques should inform their primary care physician to ensure these techniques do not conflict with other medical treatments they may be receiving.
Physical therapy
Physical therapy, supervised by a certified physical therapist, can help reduce OA-related pain, usually by strengthening the muscles and tendons that support the joint. A brace can also hold the joint in a neutral position. Typically, the first goal is stretching to improve the range of motion. Then comes strengthening the surrounding muscles, and then a plan for aerobic exercise, such as swimming or bicycling, to increase overall fitness and control weight.
One of the more dramatic recent discoveries about OA is that deterioration progresses more rapidly in joints where there is "malalignment" of the bones. Someone who is bowlegged, for example, will have a knee joint in which the bones on the inside of the knee are closer together (because there is more cartilage deterioration) than on the outside of the knee. In a person with knock-knee the opposite is true. The bones on the outside of the knee are closer together than those on the inside. Malalignment makes cartilage damage more likely, and erosion of the cartilage brings the bones even closer, producing a vicious cycle of more erosion. In people with malaligned knees, muscle strengthening was shown in one study to actually be harmful. If your legs have become bowlegged or knock-kneed recently from your arthritis, you should consult your doctor before engaging in strenuous muscle-strengthening exercises.
Canes, braces, and orthotics
For people with OA in the legs and associated joints, braces and canes can reduce pain and may slow down further deterioration by taking some of the strain off the joints or keeping joints aligned and balanced. Braces can be elastic wraps or sleeves that can be found at any pharmacy, or they can be custom-made metal and plastic models that are quite expensive.
Orthotics, devices that fit into shoes, can cushion impacts and also redistribute strain so joints are less painful. Many rheumatologists also suggest that OA patients switch to wearing sneakers, which cushion impacts and preserve joints.
Patients should ask a doctor or physical therapist if they would benefit from a supportive device.
Anti-inflammatory drugs
OA patients have been able to get pain relief from a class of drugs called nonsteroidal anti-inflammatory drugs (NSAIDs). Some familiar medications in this class, which can be purchased without a prescription, are aspirin, ibuprofen (such as Motrin or Advil), and naproxen (such as Aleve). A prescription is needed for other NSAIDs such as Celebrex. These drugs not only reduce pain but block inflammation, a special benefit for arthritis patients.
The medications do pose risks, however. Recently, prescription drugs Vioxx and Bextra, which are similar to Celebrex, were linked to a higher risk of heart attacks. The manufacturers, urged by the Food and Drug Administration, have stopped selling them. Celebrex is still available.
The FDA, after reviewing many studies of NSAIDs, announced two basic conclusions. First, all of these drugs raise the risk of heart trouble. But, second, it remains unclear just how much that risk is increased. Some studies implied a tiny rise or even none at all, while other studies pointed to a big jump. So rather than banning ibuprofen, naproxen, and Celebrex, the agency asked the drug manufacturers to add large warning labels about the heart risks.
Lower doses of these drugs appear to be safer, according to some recent research. This means OA patients should consult with their doctors about the safest effective dose. And people with high blood pressure or other heart disease risk factors should be watched carefully if they use these drugs for pain on a daily basis.
The heart isn't the only concern with NSAIDs. There are well-documented worries about stomach ulcers, even with Celebrex, which is supposed to be easier on the stomach. Patients can add a prescription drug called a proton-pump inhibitor, which protects the stomach. Some examples of these inhibitors are Nexium and Prilosec. Some come in generic versions such as omeprazole, which are less expensive.
Analgesic drugs
For mild to moderate OA pain, acetaminophen is part of the first line of treatment. Some common brand names are Tylenol and certain types of Excedrin, and they are available without a prescription at pharmacies. Acetaminophen relieves pain but does not reduce inflammation.
Some patients with more advanced disease and who have intermittent severe pain can benefit from prescription medications like Ultram or tramadol, or even stronger opioid medications like Vicodin, which contains hydrocodone. These medications are often necessary for patients with "end stage" hips or knees who are unable to undergo surgical replacement because they have heart or lung disease. Though drowsiness is an opioid side effect, that doesn't matter if the medications are taken at bedtime; these drugs may indeed help patients who feel pain more acutely at night and have trouble sleeping. Patients are often scared to take opioids, fearing addiction. But the use of time-release oral and skin-patch formulations decreases the risk of abuse. Moreover, research has indicated that the risk of addiction is small in patients with arthritis, especially when the drugs are used intermittently, and that it generally occurs only in people with a previous history of substance abuse.
Injections into the joint
When pain is severe but localized in one joint, a corticosteroid injection directly into the joint may be recommended to reduce inflammation. Such injections can provide relief for months at a time, but don't stop the underlying cartilage degeneration. Joints should not be injected more than four times a year.
For people with OA of the knee, an alternative or supplementary treatment is the injection of fluids called hyaluronans into the joint to make movement easier. Hyaluronic acid is one of the components of joint fluid that “lubricates” the joint. These compounds may also have other anti-inflammatory effects. The procedure, which is done in a doctor's office, is known as "viscosupplementation." Vicosupplementation is not for everyone, because not everyone gets relief. The best candidates have moderate, rather than severe, disease, with some cartilage damage but no bone-on-bone contact. These injections are given in a series of three or five weekly shots (depending on the specific preparation), though a single injection has recently been approved and may reduce pain for up to six months.
Complications of injection therapy are unusual, but infection occurs on rare occasions and should be treated so the joint does not sustain damage. Signs of infection include fever and swelling or redness at the injection site.
Surgery and replacement
For advanced cases of OA, if conservative treatments cease to provide relief and good quality of life, joint surgery is the next option.
Arthroscopic surgery for OA—using very small incisions to insert a camera and then scrape and clean out the joint—used to be a common procedure. But now the surgery is not generally recommended for arthritis; a scientific study has shown that a patient group who received a sham surgery fared just as well. However, there are some patients for whom this may be helpful—those with certain forms of cartilage damage associated with osteoarthritis.
In a select group of individuals with OA of the knee, the recommended treatment is osteotomy, in which a surgeon cuts away part of the bone to relieve pressure on damaged cartilage by repositioning the joint and redistributing weight properly. Recovery can take six to 12 months, and further surgery may be required if deterioration continues.
Joint replacement, or arthroplasty, is also a common surgical option for patients with very advanced OA, when the joint has deteriorated beyond repair. The entire joint—most often the hip or knee—is removed and replaced with a mechanical one. Patients who have not yet developed appreciable muscle weakness and who would medically withstand the stress of surgery are ideal candidates. The artificial joint is usually made of titanium or cobalt chrome and lined with a high-grade medical plastic to keep the joint moving smoothly. Implants may last as long as 30 years, although the average lifespan of an implant is about 15 years.
There are two types of replacements: cemented and uncemented. The cemented type is glued right to the bone. These are usually the better choice for older patients with weaker bones, because the cement holds the implant in place despite bone weakness; on the other hand, cement particles can break away and a further replacement (known as a revision), if one is needed, may be harder to perform. Uncemented implants, which rely on natural bone growth attaching to the prosthesis, are often used for younger patients. These implants are easier to replace than the cemented kind, but recovery takes longer because it depends on bone growth. Other risks of replacement surgery include infection and blood clots.
Surgeons have figured out how to insert implants using smaller incisions, reducing recovery time. But recovery is still a difficult process and should not be underestimated. Immediately after the surgery and for many days thereafter, patients may experience a lot of pain, caused mostly by muscles that were pushed and pulled during the operation. Patients are often given morphine for the pain while in the hospital.
Rehabilitation begins the day after surgery and continues either in the patient's home or at a rehabilitation facility, supervised by a physical therapist. Therapy focuses on rebuilding strength and regaining flexibility and range of motion in the joint. The success of the procedure depends, in large part, on the dedication of the patient to the rehabilitation process, which takes time, effort, and motivation. Recovery from a hip replacement procedure usually takes at least four weeks to regain most strength and motion, and about six months to completely regain it.
Last reviewed on 7/21/09
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