Osteoarthritis: conservative treatment options
X-ray of the knee, side view, showing severe osteoarthritis.
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Routinely referred to as degenerative joint disease, or “wear and tear,” osteoarthritis (OA) is a debilitating condition causing pain and stiffness that significantly limit the lifestyle of more than 27 million individuals in the United States. OA accounts for approximately 25% of primary care visits annually.1
Defined as degeneration of the cartilage and underlying bone within a joint, in addition to bony overgrowth, OA most commonly affects the hips, knees, spine, and hands.2 Advanced age (older than 65 years) is the factor most frequently associated with OA; other contributing factors include genetics, obesity, and trauma. Symptoms, which range from mild to debilitating, often lead to significant lifestyle limitations as a consequence of pain and decreased function. According to the Centers for Disease Control and Prevention (CDC),3 80% of patients with OA have some limitation of mobility, while 25% are unable to perform the activities of daily living (ADLs). These statistics underscore that it is essential for primary care providers to be aware of the conservative treatment measures available for OA.
Currently recommended conservative treatments are weight loss, physical therapy/exercise, activity modification, drugs, braces/orthotics, and intra-articular injections (Figure 1).4 Each of these measures has proved helpful for some patients, but treatment should be individualized and based on the degree of arthritis and disability and on any comorbidities that the patient may have. Treatment options can be expensive and may not elicit desired outcomes; therefore, clinicians must consider cost as well as potential risk/benefit for the patient before initiating treatment. By taking all of these variables into consideration and choosing the best treatment for individual patients, primary care providers can decrease pain and increase function, thus improving patients' satisfaction and reducing the number of patients who seek nonoperative treatment from a specialist, which is not always available or necessary.
An initial treatment option for OA is activity modification. More often than not, patients are capable of pointing out specific activities that worsen their pain, such as climbing stairs, squatting and stooping, bending, sitting for long periods of time, heavy lifting, walking long distances, and high-impact exercises. Whereas simply avoiding these is enough for some patients, others may have to modify work level and/or athletic activities. According to the American Academy of Orthopaedic Surgeons (AAOS),5 this may mean switching from high-impact exercises such as running and competitive sports to low-impact exercises such as swimming and walking. As irrelevant as this change may seem, activity modification has been shown to reduce and/or relieve arthritic pain for many.
Obesity can be a predisposing factor for OA. Studies indicate that approximately 66% of individuals with a diagnosis of OA are overweight or obese.6 Although it is common to see obese patients with arthritic pain, many will state that their joint pain prevents them from exercising and losing weight. This may be a legitimate statement, but it is the clinician's responsibility to educate such patients about other methods of losing weight (eg, behavior modification, pharmacologic treatment, weight loss surgery) because a self-discipline or compliance problem is often present.7
Weight loss is advantageous for one's overall health and has proved to be the most patient-controlled, cost-efficient long-term treatment measure that can be initiated without a provider's order; furthermore, it can be accomplished at one's own pace. According to the Framingham Study, if a female patient loses 24.25 kg (11 lb), her risk for OA is decreased by 50%.8 Another study revealed a fourfold reduction in the amount of weight distributed across the knee joint for each pound lost.9 For example, a patient who loses 10 lb reduces weight across the knee joint by 40 lb, decreasing pain significantly.7 Although weight loss can be challenging, it currently holds a moderate recommendation from the AAOS for patients with symptomatic OA and a body mass index (BMI) of 25 or higher10, and weight loss has been shown to reduce the amount of stress on joints, resulting in decreased pain and improved function.11
Physical therapy and exercise
Physical therapy is commonly prescribed for individuals with OA. Several modalities are available, including manual therapy, aquatic therapy, strength training, electrical stimulation, and balance and proprioception training.12 When considering physical therapy as a potential treatment option, the provider must take several factors into account, including the severity of the patient's symptoms and the radiographic findings.13 According to Brakke et al,12 patients with mild disease and a score of 6 or greater on the numeric pain scale are more likely to have a positive outcome than are those with advanced OA. Therefore, this treatment may be most beneficial early on because it allows patients to improve muscle strength and range of motion. The AAOS has issued a strong recommendation for patients with symptomatic OA of the knee to participate in self-management programs, strength training, low-impact aerobic exercise, and neuromuscular education, and to engage in physical activity consistent with national guidelines.10
Although physical therapy is an effective treatment option for patients with OA, it is not practical for many because of cost, lack of transportation, inconvenience, and other factors. In such circumstances, a patient may find a self-management program effective. Providers should offer patients exercises to perform at home and encourage other low-impact activities, such as walking, bicycle riding, and swimming, based on their condition and the joints affected. Walking in general has been shown to strengthen muscles and bones, reduce back pain, and lower body weight, decreasing the amount of stress on joints and therefore decreasing pain.14
When providing patients with a home exercise program, the provider should stress that engaging in exercise is a goal to work toward over time and that the extent and duration of the exercises performed can be increased gradually. Patients may not experience much benefit until they have been exercising consistently as instructed for 6 to 8 weeks, but providers should encourage them to continue because perseverance is likely to result in long-term pain relief.3 According to the CDC,3 the recommendations summarized by the acronym SMART (Figure 2) are good for patients with OA to abide by because some physical activity or exercise is better than none at all.