Management of osteoarthritis

Key Points

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Osteoarthritis (OA) is the most common form of arthritis, and pain is its most common symptom.
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The aims of treatment are to reduce pain, improve health-related quality of life, maximize activity, and optimize participation.
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Management of OA should be tailored to the individual based on shared decision making between the patient and their health care provider(s), considering patient preferences and values, the disease phenotype, and comorbid medical conditions.
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Management of OA requires a combination of multiple modalities that can include psychosocial, physical, occupational, and pharmacologic therapies, as well as surgical interventions.
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Patient education and exercise are the cornerstones of successful management of all patients with OA.
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Oral and topical pharmacologic therapies can be effective in relieving pain due to OA.
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Intraarticular glucocorticoids are useful in the symptomatic treatment of OA in some joints.
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Intraarticular hyaluronate products remain controversial in the symptomatic treatment of OA.
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Surgical interventions are an option for some patients whose disease fails to respond to nonsurgical interventions.

Introduction

Osteoarthritis (OA) is a condition that affects all components of the joint, including articular cartilage, subchondral bone, synovium, tendons, and muscles ( Chapter 185 ) and has numerous presentations ( Chapter 183 ). The diagnosis of OA should be made by history and physical examination and confirmed by conventional radiographic imaging if necessary. Alternative diagnoses should be excluded with appropriate laboratory tests and imaging. Monoarticular, oligoarticular, and polyarticular involvement may or may not be evident on physical and/or radiographic examination ( Chapter 187 ) at the time of symptom onset ( Chapter 188 ). Nonetheless, a treatment plan can be formulated to address symptoms even early in the course of osteoarthritis. The progression of disease varies among individuals regarding pace, severity, and the number of joints involved. Treatment, too, will vary based on these phenotypic features, as well as patient preferences and values. In addition, each patient should be assessed for the presence of medical comorbidities, such as hypertension and cardiovascular disease including heart failure, gastrointestinal (GI) bleeding risk, and chronic kidney disease that might have an impact on the ability to participate in exercise, and on the risk for side effects from certain pharmacologic agents. Consideration should be given to a history of injuries or surgical procedures, as well as access to and availability of treatment options, for instance, within a reasonable geographic area. The treatment approach summarized in this chapter is informed by recommendations for management published by the American College of Rheumatology (ACR) in 2020, the Osteoarthritis Research Society International (OARSI) in 2019, and the European League Against Rheumatism (EULAR) in 2018. Additional guidelines were issued by the National Institute for Clinical Excellence (NICE) in 2014 and the American Academy of Orthopaedic Surgeons (AAOS) in 2013.

Core Principles in Osteoarthritis Management

Education

There is universal agreement among national and international guidelines across subspecialties that, once the diagnosis of OA has been made, clinicians should provide all patients with education about the disease, its nature and course, as well as on self-management and treatment options. A range of practitioners, including those in family medicine, internal medicine, rheumatology, orthopedic and plastic surgery, rehabilitation medicine, and physical and occupational therapy, may be involved in these educational efforts at various points in the course of the disease. The educational process should include a discussion of the goals of therapy, namely, the control of symptoms, particularly pain, and optimization and maintenance of physical function so that patients can maximize quality of life, activity, and participation. Management aims not merely for a patient-acceptable state, but one that also includes training in ergonomic principles and pacing of activities. Education is an ongoing process and requires reinforcement and expansion at various points in treatment as the patient’s needs evolve. In addition to one-on-one discussions with providers, evidence supports the delivery of educational content in self-efficacy and self-management programs for lower extremity OA, but not for hand OA. These programs use multidisciplinary group–based formats combining sessions on skill-building (goal setting, problem-solving, positive thinking), education about the disease and about medication effects and side effects, joint protection measures, and fitness and exercise goals and approaches. Health educators, fitness instructors, nurses, physical therapists, occupational therapists, physicians, and patient peers may lead in person or online sessions.

Exercise

An ever-increasing literature supports the use of exercise in the management of OA in virtually all affected patients, regardless of the location of involved joints. An exercise program can reduce pain, increase or maintain range of joint motion, increase or maintain muscular strength, improve mobility and participation in activities, and reduce functional limitations. The introduction to exercise as an appropriate therapeutic intervention for OA will often come as a result of a prescription for physical and/or occupational therapy. There have been numerous randomized controlled trials and systematic reviews of trials of different exercise programs in patients with hip and knee OA. These studies conclude that programs of exercise therapy are able to decrease pain and improve functional capacity in patients with OA. The broad menu of exercise options includes range of motion exercises, stretching exercises, aerobic activities (walking, stationary or outdoor biking), strength training (exercise bands, free weights, weight machines), balance training, neuromuscular exercise, aquatic exercise, yoga, and tai chi. The quantity of studies for each exercise type varies depending on the location of OA and the type of exercise evaluated, and the quality of studies ranges from low to high. For any specific disease phenotype, there is generally not enough high-quality comparative literature to rank one type of exercise as superior to any other. Nonetheless, structured exercise programs can often provide the foundation of treatment for most OA patients and may include one or more forms of exercise at a given time. Exercises should be adapted according to the presence or absence of a painful episode of OA. During painful episodes, isometric exercises such as quadriceps contraction or exercises in a nonloading position (cycling, rowing with adapted tools) or in a partial nonloading position (aquatic exercises) might be proposed. During painless or less painful periods, the exercise program could include stretching and muscle performance exercises. Whatever the type of exercise prescribed, regular practice is likely to result in better outcomes, and although not well studied, many authors suggest that exercise be performed at least three times per week. Strategies to ensure long-term adherence to the exercise program should be sought in order to enhance ongoing participation.

Individualized Treatment

The variety of symptoms OA patients report is extensive, including pain, physical disability, fatigue and sleep disturbances, reduced activities and participation in society, reduced strength, embarrassment due to aesthetic damage, joint cracking and clicking, limping, and swelling. Symptoms vary between patients over time in location and severity. Moreover, patients have personal beliefs and perceptions about their disease, resulting in different coping strategies, which influence their attitude toward different treatment options. In addition, preferences and educational and cultural backgrounds have an important impact on treatment choices. The presence of medical comorbidities and psychosocial constraints may vary as well. Thus the overall treatment program for a given patient should be arrived at by shared decision making between the health professional and the patient and individualized to the needs of the patient at that time. Similarly, long-term follow-up should be adapted to the patient’s individual needs.

Multidisciplinary Approach

As is evident from the variety of opportunities for education, exercise, and occupational interventions, a broad team of practitioners may be engaged to aid in the management of OA symptoms. Furthermore, in most patients, a single therapeutic modality may not provide an adequate clinical response. Despite the lack of adequate clinical trials establishing efficacy, multidisciplinary supervision of multimodal therapy that combines educational, behavioral, psychosocial, and physical interventions, as well as topical, oral, and intraarticular medications is commonly used for treatment of individual patients.

Behavioral, Psychosocial, and Physical Interventions

Weight Loss

Weight loss is recommended for all patients with symptomatic lower limb OA who are overweight. There is evidence that weight loss of at least 5% of body weight is associated with a small but significant improvement in both pain and physical function and that long-term weight loss of 10% to 20% of body weight has substantially more clinical and mechanistic benefits than less weight loss. Many patients with OA who are overweight have comorbid cardiovascular and metabolic conditions such as hypertension, diabetes mellitus, and coronary artery disease. Reducing weight in overweight patients may have beneficial effects on the outcomes of these conditions, in addition to OA. It is important that individualized weight loss programs are available and that they include education and follow-up, including monitoring (health professional or self).

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