by Kurt Ullman, RN
No treatment has been shown to reliably reverse the cartilage damage caused by OA. Whereas there are drugs for RA that address the underlying process of the disease and aim to stop or slow its progress, there are as yet no similar disease-modifying drugs for OA. The main goals of OA treatment are to relieve pain in and improve the function of the joint. The best treatments for OA combine pain-relieving drugs with exercise and other nondrug treatments. In more severe cases, surgery may be needed.
Exercise. Exercise is one of the mainstays of OA treatment. Far from being harmful to the joints, proper exercise can improve joint mobility and strength and reduce pain and stiffness. There are three main types of exercise: strengthening, stretching, and aerobic.
Strengthening exercises are usually performed with weights or exercise bands and can strengthen muscles that support joints affected by OA. Strong muscles around a joint can help reduce pain in the joint and improve its mobility.
Stretching exercises move joints beyond their normal range of motion and can keep your joints limber, helping you more easily carry out daily tasks. Range-of-motion exercises are similar to stretching exercises except that they seek only to maintain range of motion, not increase it. Tai chi and yoga both incorporate elements of stretching and range-of-motion exercises and can be useful for people with OA.
Aerobic exercises, such as walking or low-impact aerobics, can get your heart pumping and can keep your lungs and circulatory system in shape. Aerobic exercise can also help bring about weight loss, which is one of the most effective ways to reduce OA symptoms. Losing even a small percentage of body weight can significantly reduce the stress on the knees and hips.
Orthotic devices. Orthotic devices, such as knee braces, shoe inserts, and orthotic shoes, can redistribute the load placed on joints (particularly the knee) and thereby reduce pain. Lateral wedge inserts have been found to be particularly helpful.
Assistive devices. Assistive devices, which include canes, crutches, and walkers, can also help people with OA take stress off of affected joints. However, to have an effect they must be used correctly. For example, a cane should be used in the hand opposite the affected leg.
Joint protection. People with OA should learn to carry out their daily tasks in a way that protects their joints. Getting up from a chair, carrying groceries, and cooking are just a few activities that can be done in a more joint-friendly way. Learning to pace activities throughout the day is another important strategy. An occupational therapist can teach you these and other joint-protection strategies.
Heat and cold. Many people with OA find that applying heat and cold to joints affected by OA can help relieve symptoms. Cold, usually in the form of ice packs, can relieve pain and inflammation. Heat, whether from hot packs, paraffin wax baths, or a hot bath, can soothe the joint and reduce pain. Neither cold nor heat should be used for longer than 30 minutes at a time. Some people find that alternating between the two is particularly helpful.
Education. Education about OA and its treatments is very important for symptom relief. Arthritis self-help or self-management courses can teach you self-management techniques, including appropriate exercises and proper use of medicines. Because OA can take a heavy emotional toll, people with OA may also benefit from mental health counseling and instruction in coping skills.
Drug treatment. Drugs are very helpful for relieving OA-related pain. Acetaminophen (Tylenol) is recommended as the first choice for OA pain relief. It is inexpensive, has been shown to relieve mild to moderate joint pain, and is safe at recommended doses (although it can cause liver damage if taken in excessive amounts).
Nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Advil, Motrin IB), diclofenac (Cataflam, Voltaren), and naproxen (Aleve, Naprosyn) are more powerful pain-relievers than acetaminophen. However, they carry a risk of gastrointestinal (GI) problems such as bleeding ulcers, especially at high doses, and so are recommended only for severe pain or when acetaminophen does not control symptoms.
A class of NSAIDs called cyclooxygenase-2 (COX-2) inhibitors was introduced in the late 1990’s. COX-2’s were at first widely used in the treatment of OA because they had the same pain- and inflammationreducing effect of traditional NSAIDs but were designed to reduce the risk of GI bleeding problems. However, there later surfaced concerns about an increased risk of heart attack in people taking COX-2’s, and as a result, two COX-2’s — rofecoxib (Vioxx) and valdecoxib (Bextra) — were voluntarily pulled from the market by 2005. The only COX-2 now available is celecoxib (Celebrex).
Opioid drugs — also known as narcotic drugs — are powerful pain-relievers but are recommended in OA only if other drug treatments have not worked. Opioids have many side effects, and they also present a risk of addiction in some people. If opioids are used, guidelines recommend that weaker opioids such as codeine (usually with acetaminophen) or tramadol (Ultram) be tried first.
Topical medicines — that is, medicines applied directly onto the skin near the painful joint — may be used in treating the pain of OA. Since 2007, topical NSAIDs have been available in the United States. A possible advantage of topical NSAIDs is that they may present less of a risk of GI side effects than oral NSAIDs. Available topical NSAIDs are all formulations of diclofenac and include Voltaren gel, Pennsaid topical solution, and the Flector Patch.
Topical capsaicin is another option. Made from chili peppers, capsaicin produces a sensation of heat that irritates nerve endings and is thought to cause them to use up their pain transmitters, thus reducing the pain felt from OA.
Dietary supplements. Many dietary supplements are commonly used to treat OA. Glucosamine and chondroitin are the most popular. Both of these supplements can be found naturally in the body — glucosamine is a building block of cartilage, and chondroitin is present in cartilage. Some studies show that the combination of these two supplements brings about pain reduction and reduces cartilage loss, but other studies have not shown any impact at all. Many expert guidelines have no recommendation about glucosamine and chondroitin, although the American Academy of Orthopaedic Surgeons recommends that the combination not be prescribed.
Although many people try special diets in the hopes of improving their OA, there is no solid evidence that diet can affect OA symptoms. The main benefit of a nutritious diet is to help people lose weight if they are overweight, which can relieve pain in the weight-bearing joints.
Surgery. Surgery is a last option for OA and should be considered only in people who have chronic pain and limited movement despite the drug and nondrug treatments described above. There are several surgeries used for OA: arthroscopic debridement, osteotomy, joint replacement, and joint fusion.
In arthroscopic debridement, a surgeon inserts an arthroscope — a pencil-sized instrument that contains a light, a magnifying lens, and a camera — into the joint through a small incision. The arthroscope displays images from inside the joint on a television, allowing the surgeon to see inside the joint while he or she uses tiny instruments inserted through other small incisions to clean out bone and cartilage fragments that can cause pain and inflammation. (An arthroscope may also be used to diagnose or monitor OA.) In a similar procedure, called joint lavage, the surgeon uses a saline solution to “wash” debris from the joint.
The advantage of any type of arthroscopic surgery is that it uses small incisions, which heal more quickly. However, there are questions about the effectiveness of arthroscopic debridement, with some studies finding it has no benefit over physical and drug therapy.
Osteotomy is a more invasive procedure, in which a surgeon removes part of the bones in a joint to shift weight off of a damaged part of the joint. Osteotomy is done on the knee or hip and is most commonly used on young people, who will usually need a joint replacement later in life.
In a joint replacement, a joint is removed and replaced by metal, plastic, or ceramic parts that are inserted into the remaining bone. The procedure for joint replacement depends on the joint that is being replaced, the condition of the joint, and the skill of the surgeon. Hip and knee replacements are now often done arthroscopically, but surgeries using open incisions are still common and sometimes necessary. Hip replacement is the most established and successful joint replacement, followed by knee replacement. Replacing joints in the shoulder, elbow, ankle, wrist, or hand is less common. Spinal joints cannot be replaced.
Hip resurfacing is an alternative to total hip replacement. Instead of removing the whole top of the thighbone, the surgeon shaves off only some of the bone and resurfaces it with a metal cap. The procedure preserves much of the bone, so that a full hip replacement can be done years later if needed. It may therefore be a good option for young and physically active people. However, questions have recently been raised about its safety and effectiveness in women of all ages and in men over 55, with studies showing that these people are more likely to need a full hip replacement soon after a hip resurfacing.
For the knee, there is also an alternative to a full joint replacement. If only one part of the knee is affected by OA, a surgeon may recommend a unicompartmental replacement, which replaces only the affected part of the knee and leaves open the possibility of doing a total knee replacement later.
Finally, if an affected joint cannot be replaced and has become extremely painful, a surgeon can perform a joint fusion, or arthrodesis. Fusing the bones fixes the joint in one position but significantly reduces pain. Joint fusion is most often done in the spine and in the small joints of the hands and feet.
Last Reviewed December 9, 2011
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