In osteoarthritis (OA), the cartilage that cushions the ends of bones where they meet to form a joint wears away. The result is pain, stiffness, and limited motion in the joint. And when OA affects the weight-bearing joints in the knees and hips, it can be difficult to get around and carry out the normal tasks of daily life. Because so many people have knee or hip OA, and because knee and hip OA are so debilitating, there is no shortage of possible treatments. In fact, people with knee or hip OA, and the doctors who treat them, have dozens of treatment options at their disposal. But which of these treatment options should they choose? Which of them are most effective?
To help answer these questions, a leading group of OA experts from the Osteoarthritis Research Society International (OARSI) came together to see if they could develop an up-to-date, concise set of recommendations. The experts on the OARSI committee were from the United States, Canada, the United Kingdom, France, Sweden, and the Netherlands. The idea was that the recommendations would be a useful resource not just for doctors and other health professionals, but also for people with OA. Different countries or regions might adapt the recommendations to suit their own situations.
The experts looked at 23 sets of guidelines already in existence. They looked at research studies that had been published since those already-existing guidelines were developed. And then they worked at reaching a consensus about what recommendations to make, basing their decisions on a number of factors. These factors included their evaluations of the quality of the evidence in the older guidelines, their evaluations of the newer research, and their own clinical experience, expertise, and judgment. Eventually, they agreed on 25 recommendations out of the dozens they considered, and they gave each one a strength of recommendation rating, expressed as a percentage. The higher the percentage, the stronger the recommendation.
These recommendations are not written in stone, and the OARSI committee expects to change them as more research results come in. Nor will all the recommendations be suitable for or available to everyone. Think of the list as a tool. If your knee or hip OA is not well controlled, use the list to spark discussions with your doctor about alternatives, or additions, to your current treatment.
The first treatment recommendation is a general one. The rest are divided into three categories: nondrug treatments, drug treatments, and surgical treatments.
The best way to manage OA is to combine drug and nondrug treatments. Strength of recommendation: 96%
Eleven of the OARSI recommendations concern nondrug treatments, ranging from education to exercise to walking aids.
Education and self-management. Initially, the committee recommended, treatment should focus on what people with OA can do for themselves, rather than on treatments delivered by a health professional. People with OA should receive education about the importance of lifestyle changes, exercise, pacing of activities, weight loss, and other ways to reduce strain on affected joints. Then the emphasis should shift to encouraging them to continue with their nondrug treatments. Strength of recommendation: 97%
Regular telephone contact. Getting regular phone calls promoting self-care can help people with knee or hip OA feel better. Even if the calls are from lay personnel rather than health professionals, they can help with pain relief and improve physical functioning. Strength of recommendation: 66%
Physical therapy. It may help people with hip or knee OA if they are evaluated by a physical therapist and taught appropriate exercises to reduce pain and improve physical functioning. The physical therapist can also prescribe assistive devices such as canes and walkers if the evaluation shows that these would be appropriate. Strength of recommendation: 89%
Exercise. Everyone with hip or knee OA should be encouraged to do regular aerobic, muscle strengthening, and range-of-motion exercises to promote muscle strength, relieve pain, and improve mobility. Water exercise can reduce pain and stiffness in people with hip OA. Strength of recommendation: 96%
Weight loss. Anyone with hip or knee OA who is overweight should be encouraged to lose weight and keep it off. Weight loss can relieve pain and stiffness and improve physical functioning. Strength of recommendation: 96%
Walking aids. Using canes and crutches can reduce pain in people with hip or knee OA. People who are using or going to use canes or crutches should be taught how to use them properly (for example, that it’s best to use a cane in the hand opposite the affected knee or hip). If people have affected joints on both sides of the body, it’s better to use a standard walker or a wheeled walker. Strength of recommendation: 90%
Knee braces. For people whose knees are unstable because of OA, knee braces can decrease pain, improve stability, and reduce the risk of falling. Strength of recommendation: 76%
Footwear and insoles. Everyone with knee or hip OA should be given advice about what type of shoe is appropriate. Special insoles can reduce pain in people with knee OA and make it easier for them to walk. Strength of recommendation: 77%
Heat and cold. Some heat and cold treatments may help relieve symptoms in hip and knee OA. Heat treatments include heat packs and warm-water soaks. Cold treatments include cold packs and ice massage. Strength of recommendation: 64%
TENS. Transcutaneous electrical nerve stimulation, or TENS, can help with short-term pain control in some people with hip or knee OA. In TENS, a weak electric current is sent to nerve pathways in the body through electrodes placed on the skin near the painful area. The current is thought to stop pain messages from reaching the brain. It may also stimulate the production of endorphins, hormones that ease pain. Strength of recommendation: 58%
Acupuncture. In people with knee OA, acupuncture may help relieve symptoms. Acupuncture is a type of traditional Chinese medicine that involves inserting needles into the body at specific points. It’s not clear how acupuncture works, but it may block pain messages to the brain or stimulate the production of endorphins. Strength of recommendation: 59%
The following are the eight recommendations that involve drug treatment.
Acetaminophen. Up to 4 grams a day of acetaminophen (brand name Tylenol) can be effective as the initial choice to relieve mild to moderate pain in knee or hip OA. When it doesn’t provide enough pain relief, however, or when pain is severe and/or there is inflammation, other medicines should be used. Strength of recommendation: 92%
NSAIDs. There are concerns about the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on the gastrointestinal (GI) and cardiovascular systems. Nevertheless, the committee concluded, these drugs still have an important role in the treatment of hip and knee pain from OA. The committee recommended that the drugs be used at the lowest effective dose. If possible, they should not be used long-term. NSAIDs include standard ones such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn) and COX-2 inhibitors such as celecoxib (Celebrex), which are meant to be easier on the GI system. The committee recommended that people at high risk for GI problems use either a COX-2 inhibitor or a standard NSAID plus misoprostol (Cytotec) or a proton pump inhibitor (PPI). Misoprostol and PPIs, which include omeprazole (Prilosec) and esomeprazole (Nexium), decrease the risk of GI complications. In addition, the committee recommended that both COX-2 inhibitors and standard NSAIDs be used with caution in people at risk for cardiovascular disease. This includes people with high blood pressure, high cholesterol, or diabetes. Strength of recommendation: 93%
Topical NSAIDs and capsaicin. Topical NSAIDs applied to the skin over a painful knee can be effective used along with or instead of oral pain relievers or NSAIDs. (Currently, the only topical NSAID approved for use in the United States is diclofenac, sold as Voltaren gel.) The committee noted that GI side effects are less likely from topical NSAIDs than from oral ones, but the topical preparations can cause itching, burning, and rashes. The committee also said that capsaicin cream applied to the skin can be effective, although 40% of those who use it experience local burning, stinging, or rashes. Derived from chili peppers, capsaicin blocks pain messages to the brain. Strength of recommendation: 85%
Corticosteroid injections. Injecting corticosteroids directly into a knee or hip joint affected by OA can be helpful, particularly when pain is moderate to severe and is not responding to oral medicines or when there is localized inflammation. The committee said that there aren’t enough data to know for sure how often it is safe to give these injections, but that having more than four a year in a particular joint is generally not recommended. Strength of recommendation: 78%
Hyaluronic acid injections. A series of weekly injections of hyaluronic acid may be useful in treating hip and knee OA. Hyaluronic acid injections take longer to work than corticosteroid injections, but the benefits last longer.
The injected hyaluronic acid is meant to supplement hyaluronic acid that is found naturally in the joints and helps to lubricate and cushion them. In the United States, hyaluronic acid is approved to treat knee OA only. Examples of hyaluronic acid products are Synvisc, Supartz, and Hyalgan. Strength of recommendation: 64%
Glucosamine and chondroitin for symptom relief. Treatment with glucosamine and/or chondroitin may provide symptom relief in some people with knee OA. The committee recommended stopping them if they haven’t worked by six months. Glucosamine is a prescription drug in some countries. In the United States both glucosamine and chondroitin are sold as dietary supplements. Strength of recommendation: 63%
Glucosamine, chondroitin, diacerein, and cartilage breakdown. There is some evidence that glusosamine and chondroitin may slow cartilage breakdown in knee OA and that diacerein may slow cartilage breakdown in hip OA. (Diacerein is an anti-inflammatory drug available in some countries but not in the United States.) Strength of recommendation: 41%
Opioids. When other pain relievers don’t relieve the pain of knee or hip OA, or if an individual can’t tolerate them, the doctor can consider prescribing weak opioids. (Tramadol, brand name Ultram, and codeine are given as examples of weak opioids.) Stronger opioids should only be prescribed for severe pain in what the committee called “exceptional circumstances.” The committee also recommended that people taking opioids continue nondrug treatments and think about having surgery. Strength of recommendation: 82%
The following are the committee’s recommendations for surgeries to treat OA.
Joint replacement. When drug and nondrug treatments don’t control the symptoms of hip or knee OA, replacing the affected joint with an artificial joint is often effective. Joint replacements relieve pain and improve function. Strength of recommendation: 96%
Unicompartmental knee replacement. In about 30% of people with knee OA, only one of the knee’s three compartments is affected. If the affected compartment is one of the two side compartments, the damaged bone and cartilage in that compartment can be replaced, rather than the whole knee joint. The committee said that a unicompartmental, or partial, knee replacement is as effective as a total knee replacement in relieving pain and improving function and also brings better range of motion. Strength of recommendation: 76%
Osteotomy. In osteotomy, a surgeon cuts and realigns bones in a joint to ease pressure on damaged tissue. The committee recommended that the procedure be considered in young people with hip or knee OA. They especially recommended osteotomy in young people with hip OA when the hip has a type of misalignment called dysplasia. For young active adults with unicompartmental OA, the committee recommended high tibial osteotomy as an alternative to unicompartmental knee replacement. In high tibial osteotomy, the shinbone is reshaped to improve the knee’s alignment, and healthy bone and cartilage are realigned. The committee said that high tibial osteotomy may delay the need for a joint replacement for several years. Strength of recommendation: 75%
Joint lavage and arthroscopic debridement. In joint lavage, a surgeon flushes a saline solution through the knee to remove debris such as broken-off cartilage pieces. The surgeon does this using an arthroscope, a tube-like instrument inserted into a small incision. In arthroscopic debridement, the surgeon removes overgrown or torn tissue from the joint. Often, lavage is done as part of the debridement procedure. The use of lavage and debridement in knee OA are controversial, with some studies showing that they bring short-term relief and others suggesting that any improvement comes from a placebo effect. Strength of recommendation: 60%
Joint fusion after knee replacement failure. In joint fusion, the ends of the bones that meet in a joint are cut so that they fit together. Then they are held in place by pins, plates, or screws until they grow together. The committee recommended that if a knee replacement in a person with OA has failed and cannot be fixed, the affected knee be fused as a “salvage procedure.” After the fusion, the knee should be painless and stable. A fused knee joint is also rigid, however, making it difficult to climb stairs or sit in a theater or airplane. Strength of recommendation: 69%
The original recommendations, along with the committee members’ description of how they made their choices, were published in the February 2008 issue of the journal Osteoarthritis and Cartilage. In January 2010, that journal published a research update by OARSI researchers, based on studies that came out after their initial review. In the update, researchers noted that the OARSI Treatment Guidelines Committee would meet in 2010 to decide whether the new findings warrant updating the guidelines.