Treatment Options for Osteoarthritis
There are multiple ways of approaching the management of patients with moderate to severe osteoarthritis, and this discussion will focus on a combination of behavioral change, medication and lifestyle, all of which affect disease. Osteoarthritis rarely occurs in the absence of other medical conditions; it appears frequently in combination with obesity, diabetes, cardiovascular disease and advancing age. Loss of cartilage inevitably leads to bone grinding against bone, a painful condition, whether this occurs in the spine, hip or knee. As a first principle, strengthening the muscles across the joint (paravertebral musculature in the spine, thigh muscles of the lower extremity) will help to diminish direct forces of compression and, effectively, “unload” the joint. Needless to say, weight reduction will augment muscle strengthening, again leading to diminished load bearing, with consequent decreases of pain in the compromised joint. The benefits of physical therapy cannot be overstated when it comes to muscle strengthening and increasing exercise capacity for patients with osteoarthritis.
Anti-inflammatory medications are available in over-the-counter strength as well as by prescription. The majority of patients with osteoarthritis do not have inflammatory disease, therefore a reasonable medication strategy would be to treat their condition with pain relief medications (analgesics), beginning with Tylenol and nonopiate pain relievers (including prescription medications such as tramadol). Opiates are frequently reserved for severely involved patients who cannot tolerate anti-inflammatories and are close to surgical replacement. Nonsteroidal anti-inflammatory drugs, available over-the-counter or by prescription, carry significant risk for gastrointestinal bleeding and possible injury to the kidneys. These risks are amplified by such illnesses as diabetes, cardiovascular disease and pre-existing gastrointestinal illness. When nonsteroidals are indicated for arthritis yet represent significant treatment risk, the COX-2 selective nonsteroidal Celebrex may provide significant analgesic benefit.
Topical therapies have proven useful in many cases of isolated large weight-bearing joint arthritis. Pepper-based creams including topical Zostrix (applied up to four times a day) are useful adjuncts to oral therapy, weight reduction and exercise. Local injection has also proven beneficial in many cases; lidocaine and short-acting steroid preparations placed into the osteoarthritic joint (knee, hip, shoulder) have demonstrated benefit for patients who may not tolerate oral analgesic therapy. A new class of joint injection consisting of hyaluronic acid preparations has become available over the past several years, and injections are given in weekly intervals (up to five times) with benefit for many patients with osteoarthritis.
Finally, joint replacement arthroplasty is a proven modality for surgical correction of the cartilage deficient joint. In patients with end-stage osteoarthritis, for whom oral medication, topical therapy and local injection holds little potential benefit, joint replacement confers definitive relief of chronic joint pain. Selection of patients and timing of the procedure are critical components in the decision-making process for patients with large weight-bearing joint disease. The average longevity of the replacement knee (as one example) is 15 years. It is preferable to remove an affected joint one time only, as replacement arthroplasty can be technically difficult and materials science has yet to catch up with our increased life expectancy.
In summary, therapeutic approaches to osteoarthritis management require a combinatory approach in almost every case, with recommendations individualized according to the presence of specific illnesses in a given patient. Inevitably however, weight reduction, muscle strengthening programs, analgesic medication and eventual joint replacement can enhance the quality of life for patients with moderate to severe osteoarthritis.
Published On: July 14, 2006