Ongoing research reveals promise for future laboratory studies that may show the presence of specific markers, such as chondroitin sulfate epitope 846. Measurement of type II collagen in the blood or urine may help diagnose OA and monitor its progression. Another project is looking at finding and validating microRNAs, small noncoding nucleic acids, which could “yield information critical to clinical guidelines and treatment strategies for post-traumatic osteoarthritis.”15 MicroRNAs are also present in other diseases, such as cancer and heart disease.
OA affects each person differently by limiting activities of daily living (ADLs), such as walking, bathing, dressing, climbing stairs and doing household chores. In some patients, disease progression is very slow, while in others, progression occurs much more rapidly. In the early stages, the joints may ache after physical work or exercise.
Later in the course of the disease, the joint may be painful even at rest. Symptoms vary from person to person and may be intermittent. X-rays may show dramatic degeneration of the joint, and yet the patient experiences little pain. The degeneration is generally asymmetric and noninflammatory.
Many diseases include joint pain as a symptom, and this is must be considered when making a diagnosis. Since the area of joint pain may fall under the “umbrella” of rheumatic diseases, such as rheumatoid or psoriatic arthritis, those disorders must be ruled out. Metabolic and endocrine diseases can predispose to OA.
Other common causes of hip pain include trochanteric bursitis, iliopsoas tendinitis, referred pain from the lumbosacral spine, avascular necrosis, inguinal hernia and hip fracture. Knee pain may be caused by pes anserine bursitis, iliotibial band syndrome, patella tendinitis, patellofemoral pain syndrome, prepatellar bursitis and semimembranous bursitis. Hand pain occurs as a result of carpal tunnel syndrome, flexor tenosynovitis, ulnar nerve compression and de Quervain disease.
The best way to determine treatment goals is to discuss with the patient how OA affects his or her quality of life, that is, how the patient’s symptoms interfere with performance of ADLs. The goal varies, depending on what the individual wants to accomplish. One report noted that compared to other adults, those with arthritis had a higher average number of physically unhealthy days per month, mentally unhealthy days, total unhealthy days and activity-limited days.
The five measures of health-related quality of life included demographics; social factors; health care factors, such as access and cost barriers to obtaining care; health behaviors, such as smoking and alcohol use; and chronic health conditions, such as diabetes, weight or hypertension.16
One resource patients can utilize is the Arthritis Foundation’s Programs for Better Living series, including aquatic exercise, self-help, Tai Chi and walking. Physical therapists and aquatic specialists developed these programs to address the pain, fatigue and decreased strength that often accompany OA.
The algorithm for OA management includes nonpharmacologic therapies, pharmacologic agents and surgery. The most important nonpharmacologic approach is patient education,17 followed by a self-management approach that includes personalized social support, weight loss,18 aerobic exercise, physical therapy and muscle-strengthening exercises. These therapies can be self-directed or ordered by the appropriate provider to increase mobility.
The mission of the Arthritis Foundation includes research, education and prevention of joint diseases. The Foundation advocates movement as a therapy. The efficacy of its walking program has been validated by research data. Exercise increases aerobic capacity, muscle strength and endurance, and also facilitates weight loss.
All persons capable of exercising should be encouraged to participate in a low-impact aerobic exercise program (walking, biking, swimming).19 Quadriceps-strengthening exercises have led to improvements in pain and function.20
Advise patients that if a joint is warm, red or swollen, applying ice before starting to exercise may help. If a joint is painful and stiff, applying heat will help loosen the surrounding muscles and increase blood flow to the area. When using an exercise facility, dry heat could be utilized prior to any physical activity and tends to “soften” the body or get the muscles ready to exercise. The steam room, sauna or hot tub can be used to help with sore or achy muscles. A double-blind randomized controlled trial from Korea showed that radiofrequency neurotomy is a therapeutic alternative for chronic pain associated with OA.21
Assistive devices are often used by people whose pain or instability limits physical activity, those who are not eligible for surgery, and those who do not want surgery or who want to delay it. These devices, which include canes, walkers or wheelchairs, can help decrease pain and improve ability for ambulation. Their purpose is to provide rest to the joint during the performance of ADLs. Caution patients against prolonged use of assistive devices, as it can result in weakening of unused joints.
Supports, braces, splints and shoe orthotics are examples of external devices that can help stabilize joints, provide support, correct malalignment or prevent further joint deformity.22 Some of these appliances, such as elastic or neoprene knee supports, are available OTC. Appropriate footwear provides protection and energy conservation and is important for balance and support of joints. Custom knee braces, splints and shoe wedges are prescribed.23 These are typically fitted by physical therapists, occupational therapists or orthotists and made from many types of materials, such as plastic, metal, leather or moldable foam. Other assistive devices for ADLs are available, such as jar openers, reacher/grabbers and key covers.
Role of nutritional supplements
Use of oral glucosamine and chondroitin has been controversial over the years. Although these substances are widely recommended in Europe to help reduce joint pain, the most recent meta-analysis does not favor their use in treating OA.24
Glucosamine and chondroitin are found naturally within cartilage. There is certainly a placebo effect, as has been demonstrated in several double-blind, placebo-controlled studies.24 Since no regulatory agencies oversee production of nutritional supplements, advise patients to read the label to be sure they are purchasing a standardized extract, meaning that each capsule contains a consistent amount of each active ingredient listed on the label.
To determine whether glucosamine and chondroitin in combination is beneficial for pain relief, patients should follow directions on the label for one month. If they find the supplement helpful, then the general rule is to continue as directed on the label.
Vitamin D is touted as having many almost miraculous benefits for treating and preventing disease, including relieving OA pain and repairing structural damage. Yet a two-year clinical trial funded by the National Institutes of Health found no such benefits of vitamin D therapy. Whatever its role in OA, vitamin D is important for the metabolism of calcium in patients who are at risk of or who have osteoporosis.25
Orthopedic surgeons may prescribe vitamin C and zinc to aid in healing and for overall nutrition, usually after a patient has had joint surgery.
There are currently no prescriptive medications that prevent or decrease OA, so treatment is relegated to pain relief. Acetaminophen, which may be used in dosages up to 4 g/day, is the oral analgesic of choice for mild to moderate OA pain.26 Although the pain relief experienced may be limited, acetaminophen is indicated as first-line therapy. The FDA has been reviewing acetaminophen to determine its safety.
Nonsteroidal anti-inflammatory drugs (NSAIDs) should be added or substituted in patients who respond inadequately to acetaminophen. Aspirin, ibuprofen (Ibu-tab), naproxen (Anaprox, Naprosyn) and ketoprofen are OTC NSAIDs. Patients should be cautioned about side effects of NSAIDs, such as GI distress or bleeding. Results of a comprehensive meta-analysis of all randomized controlled trials of NSAIDs showed a two- to fourfold increased risk of cardiovascular impact.27