BLOG: Current treatment recommendations for large joint osteoarthritis
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Editor’s note: This paper reviews the current treatment recommendations for large joint osteoarthritis, including exercise, physical therapy, strengthening, neuromuscular training, weight control and analgesic medication for breakthrough pain. The author also discusses corticosteroid injections and developing individualized care plans for managing large joint OA.
- Sam Dyer, PA-C, MHS
PAOS president
Osteoarthritis is a progressive and degenerative joint disease that affects most people older than 40 years. It is characterized by cartilage degeneration and osteophyte growth at the joint line margins.
It is most commonly seen in weight-bearing joints, such as the knee and hip, but can be found in other non-weight-bearing joints of the body. Not only is there degeneration of cartilage in the joint, but also inflammation that further encourages tissue breakdown and degradation.
The clinical presentation of OA widely varies between patients. Patients generally complain of joint pain, stiffness and specific limitations of movement of the joint. The description of pain varies greatly between patients from being sharp, dull, constant, only exacerbated with activity or with lack of activity. Ultimately, OA can be diagnosed based on clinical presentation and findings on X-ray. X-rays of a joint with OA can show narrowing of the joint space, excess bone growth on the margins of the joint and densities of bone underneath cartilage. The only definitive treatment of OA is a total joint replacement; however, multiple different modalities are utilized for symptomatic management. The American Academy of Orthopedic Surgeons released clinical practice guidelines regarding the efficacy and recommendation of use of these modalities.
Exercise, physical therapy, strengthening, neuromuscular training, weight control and analgesic medication for breakthrough pain were found to be the most effective treatments of OA. Exercise and physical therapy, either with a physical therapist or through a self-management program, were recommended for both knee and hip OA, and were determined to be the most effective non-pharmacological conservative treatment.
Neuromuscular training is beneficial for knee OA and helped improve balance, proprioception, and strength in this population. When utilized with diagnosis of early knee OA, neuromuscular training also showed a decrease in OA symptoms and pain.
NSAIDs are recommended as the first-line pharmaceutical short-term treatment for knee and hip OA. Gastrointestinal upset was the predominant side effect reported, and thus should only be utilized for short term use.
Tramadol was recommended by the AAOS for pain relief in knee OA but should be prescribed with extreme caution and in short durations due to its addictive nature, ability to lower the seizure threshold and risk of serotonin syndrome when combined with other serotonergic drugs.
Weight loss is recommended in patients with a BMI of greater than 25 kg/m2 for symptom and pain reduction. In addition to the increased load on the joint, adipose tissue can release inflammatory factors called adipocytokines that can cause local inflammatory effects leading to increased pain. Obesity can reduce the efficacy of other conservative measures; thus, it is important to discuss expectations of non-surgical treatment efficacy with obese patients.
Intra-articular corticosteroid injections are strongly recommended for short-term pain relief and functional improvement in hip OA, but efficacy of this modality for knee OA was deemed “inconclusive” by the AAOS. Corticosteroid injections have been a mainstay of treatment in managing knee OA and some studies have found it effective in patients unwilling or unable to undergo a total knee arthroplasty, while other studies have found its effects to be no better than those of saline injections. Extended-release intra-articular corticosteroid formulations have displayed a positive effect on pain relief without radiographic evidence of an increased rate of disease progression. This requires continued research on the long-term effects of extended-release corticosteroid intra-articular injections and their role in symptomatic management of OA.
A multidisciplinary approach is suggested by the AAOS for symptomatic management of large joint OA due to the varied clinical presentation of the disease. Clinicians should create individualized treatment plans based on the complaints and deficits the patient is experiencing and remain up to date on current recommendations of treatment to provide the most appropriate care.
References:
AAOS board of directors. Management of osteoarthritis of the hip: Evidence-based clinical practice guideline. AAOS. https://www.aaos.org/. Published 2017. Accessed Sept. 19, 2020.
AAOS board of directors. Treatment of osteoarthritis of the knee: Evidence-based guideline, 2nd edition. AAOS. https://www.aaos.org. Published 2013. Accessed Sept. 19, 2020.
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