bone, joint, and muscle disorders
Osteoarthritis (OA)
Treatment of Osteoarthritis
Physical measures, including physical and occupational therapy, joint protection, and appropriate weight loss Medications Surgery The main goals of osteoarthritis treatment are to Relieve pain Maintain joint flexibility Optimize joint and overall function These goals are primarily achieved by physical measures that involve exercises for strength, flexibility, and endurance and rehabilitation ( Physical Therapy (PT) and Appropriate exercises—including stretching, strengthening, and postural exercises—help maintain healthy cartilage, increase a joint’s range of motion, and most importantly strengthen surrounding muscles so that they can absorb stress better. Exercise can sometimes slow down the worsening of osteoarthritis of the hip and knee. Doctors often recommended people exercise in water (such as in a pool) because water spares the joints from stress. Stretching exercises should be done daily. Exercise must be balanced with a few minutes of rest of painful joints (every 4 to 6 hours during the day), but immobilizing a joint is more likely to worsen the disease than relieve it. Using excessively soft chairs, recliners, mattresses, and car seats may worsen symptoms. People should not put pillows under their knees when reclining because doing so can cause the hip and knee muscles to become tight. (This recommendation contrasts with the recommendation that people with low back pain and sciatica put a pillow between their knees. For such people, using a pillow relieves the stress on the lower back and hip [see Sciatica ].) Moving car seats forward, using straight-backed chairs with relatively high seats (such as kitchen or dining room chairs), firm mattresses, and bed boards (available at many lumber yards), and wearing orthotics, supportive shoes, or athletic shoes are often recommended. Toilet seat risers can make standing up easier and less uncomfortable for people who have painful osteoarthritis of the knees or hips, particularly if their muscles are weak. For osteoarthritis of the spine, specific exercises sometimes help, and back supports may be needed when pain is severe. Exercises should include both muscle-strengthening as well as low-impact aerobic exercises (such as walking, swimming, elliptical machine use, and stationary bicycle riding). If possible, people should maintain ordinary daily activities and continue to perform their normal activities, such as a hobby or job. However, physical activities may have to be adjusted to limit lifting and bending in ways that can aggravate the pain of osteoarthritis. Other additional measures can help relieve pain and help people live with osteoarthritis. They include Physical Therapy (PT) , Range-of-motion exercisesdone gently in warm water are helpful because heat improves muscle function by reducing stiffness and muscle spasm. Heat therapy None Cold therapy (cryotherapy) None Shoe inserts(orthotics), supportive shoes, or athletic shoes may help reduce pain caused by walking. Special equipment(for example, canes, crutches, walkers, neck collars, elastic knee supports to protect joints, or a fixed seat placed in a bathtub to prevent too much stretching while washing) should be used as needed. Treatment None Electrical stimulation None Acupuncture None Massage None Medications are used to supplement exercise and physical therapy. Medications, which may be used in combination or individually, do not directly alter the course of osteoarthritis. They are used to reduce symptoms and thus allow more normal daily activities. A pain reliever (analgesic), such asacetaminophen, used before activities that cause discomfort or used regularly to relieve more constant joint discomfort, may be all that is needed for mild to moderate pain. Although side effects are not common, people should not takeacetaminophenin higher than recommended doses, particularly if they have liver disease or drink considerable alcohol. When takingacetaminophen, people should also make sure not to simultaneously take one of the numerous over-the-counter drug products that containacetaminophen. Sometimes, however, people may need a more potent analgesic, such astramadol. Alternatively, a Nonsteroidal Anti-Inflammatory Drugs may be taken to lessen pain and swelling. NSAIDs reduce pain and inflammation in joints and can be used in combination with other analgesics. NSAIDs also come in gel and cream forms that can be rubbed into the skin (such as Sometimes other types of pain medicine may be needed. For example, a cream made from cayenne pepper—the active ingredient iscapsaicin—can be applied directly to the skin over the joint. Doctors may also recommendlidocainepatches for pain relief, but there is no evidence these patches are effective.Duloxetine, a type of antidepressant taken by mouth, may reduce the pain caused by osteoarthritis. Muscle relaxants (usually in low doses) occasionally relieve pain caused by muscles straining to support joints affected by osteoarthritis. In older people, however, they may cause more side effects than relief. If a joint suddenly becomes inflamed, swollen, and painful, most of the fluid inside the joint may need to be removed and a special form ofcortisonemay be injected directly into the joint. This treatment may provide temporary pain relief and increased joint flexibility in some people. A series of 1 to 5 weekly injections of hyaluronate (a substance similar to normal joint fluid) into the knee joint may provide some pain relief in some people for prolonged periods of time. These injections should not be given more often than every 6 months. Hyaluronate injections are less effective in people with severe osteoarthritis and do not slow the progression of the arthritis. Several nutritional supplements (such asglucosaminesulfate and chondroitin sulfate) have been tested for potential benefit in treating osteoarthritis. So far, results are mixed, and the potential benefit ofglucosaminesulfate and chondroitin sulfate in treating pain is unclear, and they do not seem to change the progression of joint damage. There is no good evidence that any other nutritional supplements work. Surgical treatment may help when other treatments fail to reduce pain or improve function. Some joints, most commonly the hip and knee, can be replaced with an artificial joint. Replacement, particularly of the hip, is usually very successful, almost always improving motion and function and dramatically decreasing pain. Therefore, joint replacement should be considered when pain is unmanageable and function becomes limited. Because an artificial joint does not last forever, the procedure is often delayed in very young people so the need for repeated replacements can be minimized. If other treatments are ineffective, surgical procedures can be done to help relieve symptoms of back or neck osteoarthritis, particularly nerve compression. The benefit of limited, arthroscopic surgical procedures for osteoarthritis of the knee, such as repair of the meniscus or reconstruction of knee ligaments, is uncertain. A variety of methods that restore cells inside cartilage have been used in younger people with osteoarthritis (often caused by an injury) to help heal small defects in cartilage. However, such methods have not yet proved valuable when cartilage defects are extensive, as commonly occurs in older people. Sometimes the whole hip joint must be replaced. The whole hip joint is the top (head) of the thighbone (femur) and the surface of the socket into which the head of the thighbone fits. This procedure is called total hip replacement or total hip arthroplasty. The head of the thighbone is replaced with a ball-shaped part (prosthesis), made of metal. The prosthesis has a strong stem that fits within the center of the thighbone. The socket is replaced with a metal shell lined with durable plastic. A knee joint damaged by osteoarthritis may be replaced with an artificial joint. After a general anesthetic is given, the surgeon makes an incision over the damaged knee. The knee cap (patella) may be removed, and the ends of the thigh bone (femur) and shinbone (tibia) are smoothed so that the parts of the artificial joint (prosthesis) can be attached more easily. One part of the artificial joint is inserted into the thigh bone, the other part is inserted into the shinbone, and then the parts are cemented in place. Many myths about osteoarthritis remain. For example, people think that it is an inevitable part of aging, like gray hair and skin changes, that it results in little disability, and that treatment is not effective. Osteoarthritis does become more common with aging. For instance, as people age, the following occur: The cartilage that lines the joints tends to thin. The surfaces of a joint may not slide over each other as well as they used to. The joint may be slightly more susceptible to injury. However, osteoarthritis is not an inevitable part of aging. It is not caused simply by the wear and tear that occurs with years of joint use. Other factors may include single or repeated injury, abnormal motion, metabolic disorders, joint infection, or another joint disorder. Effective treatment, such as pain medications (analgesics), exercises and physical therapy, and, in some cases, surgery, is available. Ligament damage is also common with aging. Ligaments, which bind joints together, tend to become less elastic as people age, making joints feel tight or stiff. This change results from chemical changes in the proteins that make up the ligaments. Consequently, most people become less flexible as they age. Ligaments tend to tear more easily, and when they tear, they heal more slowly. Older people should have their exercise regimen reviewed by a trainer or doctor so that exercises likely to tear ligaments can be avoided. Sometimes the pain caused by osteoarthritis cannot be relieved by a simple analgesic, such asacetaminophen. More potent analgesics, such astramadol, may be required, but doctors prescribe them only when necessary, to avoid problems with side effects and possible addiction. However, these medications can cause confusion in older people. Nonsteroidal anti-inflammatory drugs (NSAIDs) that are rubbed into the skin over the affected joint may be a better option for older people. Less of the NSAID is absorbed than if it is taken by mouth, which minimizes the risk of side effects. 