Osteoarthritis medical therapy: Difference between revisions

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__NOTOC__
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{{Osteoarthritis}}
{{Osteoarthritis}}
{{CMG}}
{{CMG}}; {{AE}}[[User:DrMars|Mohammadmain Rezazadehsaatlou]][2], [[User:Irfan Dotani|Irfan Dotani]] [3].


==Overview==
==Overview==
As all diseases, the [[Osteoarthritis primary prevention|prevention]] and the early diagnosis and onetime treatment of OA play important roles patient final outcome. The treatment of OA can be categorized into two options. Treatment options of OA are: [[Osteoarthritis medical therapy|Nonsurgical]] (non-pharmacological, pharmacological, and complementary) and [[Osteoarthritis surgery|'''surgical''']] interventions. As it always was, is, and will be, the patients have this right to get the best, safest, and least invasive therapies as their first treatment options. Meanwhile, surgical interventions should be considered in patients who have responded to the first line non/less invasive therapies inadequately. Meanwhile, the [[Osteoarthritis medical therapy|non-surgical treatments]] are often effective enough as the first line in patients management. Actually, the osteoarthritis treatment is a combination of medical therapies.
==Medical Therapy==
==Medical Therapy==
Generally speaking, the process of clinically detectable osteoarthritis is irreversible, and typical treatment consists of medication or other interventions that can reduce the pain of OA and thereby improve the function of the joint.
Application of heat — often moist heat — eases inflammation and swelling in the joints, and can help improve [[blood circulation|circulation]], which has a healing effect on the local area. Weight loss and muscle strengthening are also main stays of treatment.
===Coping skills and lifestyle changes===
No matter what the severity, or where the OA lies, conservative measures, such as weight control, appropriate rest and [[exercise]], and the use of mechanical support devices are usually beneficial to sufferers. In the case of OA of the knees, knee braces, a cane, or a walker can be a helpful aid for walking and support. Regular exercise, if possible, in the form of [[walking]] or [[swimming]], is encouraged. Applying local heat before, and cold packs after exercise, can help relieve pain and inflammation, as can [[relaxation technique]]s. Weight loss can relieve joint stress and may delay progression. Proper advice and guidance by a health care provider is important in OA management, enabling people with this condition to improve their quality of life.
In 2002, a randomized, blinded assessor trial was published showing a positive effect on hand function with patients who practiced home joint protection exercises (JPE). Grip strength, the primary outcome parameter, increased by 25% in the exercise group versus no improvement in the control group.  Global hand function improved by 65% for those undertaking JPE. <ref>{{cite journal |author=Stamm TA, Machold KP, Smolen JS, ''et al'' |title=Joint protection and home hand exercises improve hand function in patients with hand osteoarthritis: a randomized controlled trial |journal=Arthritis Rheum. |volume=47 |issue=1 |pages=44-9 |year=2002 |pmid=11932877 |doi=}}</ref>
Dealing with chronic pain can be difficult and result in [[clinical depression|depression]]. Communicating with other patients and caregivers can be helpful, as can maintaining a positive attitude. People who take control of their treatment, communicate with their health care provider, and actively manage their arthritis experience can reduce pain and improve function.
===Physical therapy===
Some types of [[physical therapy]] may help according to a [[systematic review]] of trials.<ref name="pmid23128863">{{cite journal| author=Wang SY, Olson-Kellogg B, Shamliyan TA, Choi JY, Ramakrishnan R, Kane RL| title=Physical therapy interventions for knee pain secondary to osteoarthritis: a systematic review. | journal=Ann Intern Med | year= 2012 | volume= 157 | issue= 9 | pages= 632-44 | pmid=23128863 | doi=10.7326/0003-4819-157-9-201211060-00007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23128863  }} </ref>
===Dietary===
Supplements which may be useful for treating OA include:
====Glucosamine====
A molecule derived from glucosamine is used by the body to make some of the components of cartilage and synovial fluid.  Supplemental glucosamine may improve symptoms of OA and delay its progression.<ref name="pmid15855241">{{cite journal |author=Poolsup N, Suthisisang C, Channark P, Kittikulsuth W |title=Glucosamine long-term treatment and the progression of knee osteoarthritis: systematic review of randomized controlled trials |journal=The Annals of pharmacotherapy |volume=39 |issue=6 |pages=1080-7 |year=2005 |pmid=15855241 |doi=10.1345/aph.1E576}}</ref> However, a large study suggests that glucosamine is not effective in treating OA of the knee.<ref>McAlindon T, Formica M, LaValley M, Lehmer M, Kabbara K. ''Effectiveness of glucosamine for symptoms of knee osteoarthritis: Results from an internet-based randomized double-blind controlled trial.'' Am J Med 2004; 117:643-9. PMID 15501201.</ref> A subsequent [[meta-analysis]] that includes this trial concluded that glucosamine hydrochloride is not effective and that the effect of glucosamine sulfate is uncertain.<ref name="pmid17599746">{{cite journal |author=Vlad SC, Lavalley MP, McAlindon TE, Felson DT |title=Glucosamine for pain in osteoarthritis: Why do trial results differ? |journal= |volume=56 |issue=7 |pages=2267-2277 |year=2007 |pmid=17599746 |doi=10.1002/art.22728}}</ref>
====Chondroitin====
A [[meta-analysis]] of [[randomized controlled trials]] found no benefit from chondroitin.<ref name="pmid17438317">{{cite journal |author=Reichenbach S, Sterchi R, Scherer M, ''et al'' |title=Meta-analysis: chondroitin for osteoarthritis of the knee or hip |journal=Ann. Intern. Med. |volume=146 |issue=8 |pages=580-90 |year=2007 |pmid=17438317 |doi=}}</ref>
====Other supplements====
*'''Boswellia''', an herbal supplement known in Aryuvedic medicine. It is widely available in health food stores and online.
*'''[[Antioxidant]]s''', including [[Vitamin C|vitamins C]] and [[Vitamin E|E]] in both foods and supplements, provide pain relief from OA. <ref>McAlindon TE, Jacques P, Zhang Y, et al. Do antioxidant micronutrients protect against the development and progression of knee osteoarthritis? Arthritis Rheum 1996; 39:648-656</ref>
* '''[[Hydrolyzed collagen (hydrolysate)]]''' (a gelatin product) may also prove beneficial in the relief of OA symptoms, as substantiated in a German study by Beuker F. et al. and Seeligmuller et al. In their 6-month placebo-controlled study of 100 elderly patients, the verum group showed significant improvement in joint mobility.
* '''[[Ginger]] (rhizome) extract''' - has improved knee symptoms moderately.<ref>Altman RD, Marcussen KC. Arthritis Rheum. 2001 Nov; 44(11):2531-8</ref>
* '''[[Methylsulfonylmethane|Methylsulfonylmethane (MSM)]]''': A small study by Kim et al. suggested that MSM significantly reduced pain and improved physical functioning in OA patients without major adverse events (Kim et al). The authors cautioned that although this short pilot study did not address the long-term safety and usefulness of MSM, they suggest that physicians should consider its use for certain osteoarthritis patients.
* '''[[S-adenosyl methionine]]''': small scale studies have shown it to be as effective as [[NSAID]]s in reducing pain, although it takes about four weeks for the effect to take place.
* '''[[Selenium]]''' deficiency has been correlated with a higher risk and severity of OA, therefore selenium supplementation may reduce this risk.<ref>{{cite web |url=http://www.unc.edu/news/archives/nov05/jordan111005.htm |title=UNC News release -- Study links low selenium levels with higher risk of osteoarthritis |accessdate=2007-06-22 |format= |work=}}</ref>
* '''Vitamins B9 ([[folate]]) and [[Vitamin B12|B12]]''' ([[cobalamin]]) taken in large doses significantly reduced OA hand pain, presumbably by reducing systemic inflammation.<ref>Flynn MA, Irvin W, Krause G.  J Am Coll Nutr. 1994 Aug; 13(4):351-6.</ref>
* '''[[Vitamin D]] deficiency''' has been reported in patients with OA, and supplementation with [[Vitamin D3]] is recommended for pain relief.<ref>Arabelovic S, McAlindon TE. Curr Rheumatol Rep. 2005 Mar; 7(1):29-35.</ref>
*  Bone Morphogenetic Protein 6 (BMP-6) has recently been shown to have a functional role in the maintenance of joint integrity and is now being produced in an orally ingested form.  <ref> K. Bobacz, R. Gurber, A Soleiman, L. Erlacher, J.S. Smolen, and W.B. Grainger, Arthritis & Rheumatism 2003 Sep; 48(9) 2501 </ref>
Other nutritional changes shown to aid in the treatment of OA include decreasing [[saturated fat]] intake<ref>Wilhelmi G.  Z Rheumatol. 1993 May-Jun; 52(3):174-9. Vasishta VG et al, Rotational Field Magnetic Resonance (RFQMR) in treatment of osteoarthritis of the knee joint, Indian Journal of Aerospace Medicine, 48 (2), 2004; 1-7.</ref> and using a low energy diet to decrease body fat.<ref>Christensen R.  Osteoarthritis Cartilage. 2005 Jan; 13(1):20-7.</ref>  Lifestyle change may be needed for effective symptomatic relief, especially for knee OA.<ref>De Filippis L et al. Reumatismo. 2004 Jul-Sep; 56(3):169-84.</ref> Reducing sugar, processed foods, fatty foods and [[Solanaceae|nightshade vegetables]] have helped many. According to Dr. John McDougall, a low fat vegetarian diet can reduce arthritis symptoms. A macrobiotic diet has been known to reduce symptoms as well.
===Medications===
====Acetaminophen====
A mild pain reliever may be sufficiently efficacious. [[Acetaminophen]] (tylenol/paracetamol), is commonly used to treat the pain from OA, although unlike NSAIDs, acetaminophen does not treat the inflammation. A [[randomized controlled trial]] comparing [[acetaminophen]] to [[ibuprofen]] in x-ray proven mild to moderate osteoarthritis of the hip or knee found that equal benefit.<ref name="pmid2052056">{{cite journal |author=Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI |title=Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee |journal=N. Engl. J. Med. |volume=325 |issue=2 |pages=87-91 |year=1991 |pmid=2052056 |doi=}}</ref> However, [[acetaminophen]] at a dose of 4 grams per day can increase [[liver function test]]s.<ref name="pmid16820551">{{cite journal |author=Watkins PB, Kaplowitz N, Slattery JT, ''et al'' |title=Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial |journal=JAMA |volume=296 |issue=1 |pages=87-93 |year=2006 |pmid=16820551 |doi=10.1001/jama.296.1.87}}</ref>
====Non-steroidal anti-inflammatory drugs====
In more severe cases, [[non-steroidal anti-inflammatory drug]]s (NSAID) may reduce both the pain and inflammation. These include medications such as [[diclofenac]], [[ibuprofen]] and [[naproxen]]. High doses are often required. All NSAIDs act by inhibiting the formation of [[prostaglandin]]s, which play a central role in inflammation and pain. However, these drugs are rather taxing on the [[gastrointestinal tract]], and may cause [[stomach]] upset, [[cramp]]ing, [[diarrhoea]], and [[peptic ulcer]].


====COX-2 selective inhibitors====
=== Non-pharmacological ===
Another type of NSAID, [[COX-2 selective inhibitor]]s (such as [[celecoxib]], and the withdrawn [[rofecoxib]] and [[valdecoxib]]) reduce this risk substantially. These latter NSAIDs carry an elevated risk for [[cardiovascular disease]], and some have now been withdrawn from the market.
Nonpharmacologic therapy is consisted of physical therapy and specific type of physical exercises, bracing and splinting:<ref name="pmid23446069">{{cite journal |vauthors=Lauche R, Cramer H, Langhorst J, Dobos G |title=A systematic review and meta-analysis of medical leech therapy for osteoarthritis of the knee |journal=Clin J Pain |volume=30 |issue=1 |pages=63–72 |date=January 2014 |pmid=23446069 |doi=10.1097/AJP.0b013e31828440ce |url=}}</ref><ref name="pmid23876571">{{cite journal |vauthors=Lauche R, Langhorst J, Dobos G, Cramer H |title=A systematic review and meta-analysis of Tai Chi for osteoarthritis of the knee |journal=Complement Ther Med |volume=21 |issue=4 |pages=396–406 |date=August 2013 |pmid=23876571 |doi=10.1016/j.ctim.2013.06.001 |url=}}</ref><ref name="pmid28121996">{{cite journal |vauthors=Zhang Y, Huang L, Su Y, Zhan Z, Li Y, Lai X |title=The Effects of Traditional Chinese Exercise in Treating Knee Osteoarthritis: A Systematic Review and Meta-Analysis |journal=PLoS ONE |volume=12 |issue=1 |pages=e0170237 |date=2017 |pmid=28121996 |pmc=5266306 |doi=10.1371/journal.pone.0170237 |url=}}</ref>
* Physical therapy results in short-term pain reduction, and improvement in physical function in the diseased [[joint]] to preserve its the ability for daily tasks like walking, dressing, and even bathing.
* Walking can reduce pain from osteoarthritis. A 1997 [[randomized controlled trial]] found 1 hour of walking based aerobic activity three times per week showed, over 18 months that older people with symptomatic osteoarthritis had consistent modest improvement in self-reported pain and disability compared with participation in health education programs. Futhermore, there seemed to be some correlation between increased amount of exercise and greater improvements in pain<ref name="pmid8980206">{{cite journal| author=Ettinger WH, Burns R, Messier SP, Applegate W, Rejeski WJ, Morgan T et al.| title=A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). | journal=JAMA | year= 1997 | volume= 277 | issue= 1 | pages= 25-31 | pmid=8980206 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8980206  }} </ref>.
* On the other hand, resting is another important healing factor in OA.
* Bracing and splinting as other methods help to support painful or unstable [[joints]].
* Using a cane can help decrease the weight pressure in diseased [[hip]] or [[knee]], but it should be used on the contralateral side of the affected joint.


====Corticosteroids====
=== Analgesics ===
Intraarticular [[corticosteroid]]s of the [[knee]] may reduce pain for one week after the injection.<ref name="pmid16625636">{{cite journal| author=Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G| title=Intraarticular corticosteroid for treatment of osteoarthritis of the knee. | journal=Cochrane Database Syst Rev | year= 2006 | volume= | issue= 2 | pages= CD005328 | pmid=16625636 | doi=10.1002/14651858.CD005328.pub2 | pmc= | url= }} </ref> However, a [[randomized controlled trial]] found "No additional benefit results from adding an intra-articular injection of 40 mg of corticosteroid before exercise in patients with painful OA of the knee."<ref name="pmid25822572">{{cite journal| author=Henriksen M, Christensen R, Klokker L, Bartholdy C, Bandak E, Ellegaard K et al.| title=Evaluation of the benefit of corticosteroid injection before exercise therapy in patients with osteoarthritis of the knee: a randomized clinical trial. | journal=JAMA Intern Med | year= 2015 | volume= 175 | issue= 6 | pages= 923-30 | pmid=25822572 | doi=10.1001/jamainternmed.2015.0461 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25822572  }} </ref>
Drug therapy in OA management plays an important role in relieving pain and slow downing the progression of this disease. Meanwhile, common medications are:<ref name="pmid17636601">{{cite journal |vauthors=Watson M, Brookes ST, Faulkner A, Kirwan J |title=WITHDRAWN: Non-aspirin, non-steroidal anti-inflammatory drugs for treating osteoarthritis of the knee |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD000142 |date=July 2007 |pmid=17636601 |doi=10.1002/14651858.CD000142.pub2 |url=}}</ref><ref name="pmid15846645">{{cite journal |vauthors=Towheed TE, Maxwell L, Anastassiades TP, Shea B, Houpt J, Robinson V, Hochberg MC, Wells G |title=Glucosamine therapy for treating osteoarthritis |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD002946 |date=April 2005 |pmid=15846645 |doi=10.1002/14651858.CD002946.pub2 |url=}}</ref><ref name="pmid16437479">{{cite journal |vauthors=Towheed TE, Maxwell L, Judd MG, Catton M, Hochberg MC, Wells G |title=Acetaminophen for osteoarthritis |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD004257 |date=January 2006 |pmid=16437479 |doi=10.1002/14651858.CD004257.pub2 |url=}}</ref>
* '''[[NSAIDs|NSAIDs (Non-steroidal anti-inflammatory drugs)]]:''' Including [[acetaminophen]], [[aspirin]], [[ibuprofen]] (e.g. Advil), [[naproxen]] (e.g. Aleve), [[diclofenac]], [[cyclooxygenase-2 inhibitors]] ([[celecoxib]]-Celebrex) are used to reduce the [[inflammation]] and swelling as a common finding in OA.
** Meanwhile,  the [[glucosamine]] and [[chondroitin sulfate]] supplements are used in the United States as an alternative treatment for OA. For patients experiencing moderate-to-severe pain due to the knees osteoarthritis or spine osteoarthritis, they might be helpful by interacting with the diseased [[cartilage]].


One trial that compared [[corticosteroid]] injections every three months to placebo for two years<ref name="pmid12571845">{{cite journal| author=Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J et al.| title=Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. | journal=Arthritis Rheum | year= 2003 | volume= 48 | issue= 2 | pages= 370-7 | pmid=12571845 | doi=10.1002/art.10777 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12571845  }} </ref> found improvements in outcomes ranging from none to small for the [http://www.rheumatology.org/practice/clinical/clinicianresearchers/outcomes-instrumentation/WOMAC.asp WOMAC pain score]<ref name="pmid3068365">{{cite journal |author=Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW |title=Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee |journal=J. Rheumatol. |volume=15 |issue=12 |pages=1833–40 |year=1988 |month=December |pmid=3068365 |doi= |url= |issn=}}</ref>
* '''[[Analgesics]]:''' Including [[acetaminophen]] (e.g. [[Tylenol]]), or [[tramadol]] (e.g. Ultram) are used to reduce the pain, without any effects on [[inflammation]] or swelling. [[Analgesics]] are recommended for patients experiencing mild to moderate pain because they could cause a limited variety of side effects for patients.
* '''Topical analgesics:''' These creams are usually used to reduce the pain in the diseased joint. They applied directly to the skin over the affected area. These creams consist of counterirritants (wintergreen and eucalyptus) which have a great effect on pain reduction. Capsaicin cream is derived from chili peppers and found to be effective in treating osteoarthritis pain, which can be applied as an adjunct therapy to the OA standard treatments. This group of therapies compared to NSAIDs had fewer [[Adverse effect (medicine)|adverse effects]].


In 2017, a randomized, double-blind, clinical trial evaluated the effect of intra-articular triamcinolone compared to saline on knee cartilage volume and WOMAC pain in patients with symptomatic knee osteoarthritis. 140 patients were randomized to receive 1mg of intra-articular triamcinolone or saline once every 12 weeks for 24 months. Knee cartilage volume was evaluated by MRI and interpreted by blinded independent radiologists specializing in musculoskeletal and joint diseases. Intra-articular triamcinolone was associated with significantly greater cartilage volume loss than normal saline at 24 months with no significant difference in pain or mobility. Additionally, triamcinolone was associated with a slightly increased rate of patient-reported adverse events. This study represents the latest evidence against the use of intra-articular coroticosteroid injections for the management of knee osteoarthritis, which is currently widely used in clinical practice.<ref name="pmid28510679">{{cite journal| author=McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M et al.| title=Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. | journal=JAMA | year= 2017 | volume= 317 | issue= 19 | pages= 1967-1975 | pmid=28510679 | doi=10.1001/jama.2017.5283 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28510679  }} </ref>
{| class="wikitable"
|+[[Osteoarthritis medical therapy|Medications]] Used for [[Osteoarthritis|OA]]
! colspan="1" rowspan="1" |Medication
! colspan="1" rowspan="1" |Typical dosage
|-
| colspan="1" rowspan="1" |Acetaminophen
| colspan="1" rowspan="1" |650 to 1,000 mg four times per day
|-
| colspan="1" rowspan="1" |Celecoxib (Celebrex)
| colspan="1" rowspan="1" |200 mg per day
|-
| colspan="1" rowspan="1" |Diclofenac sodium
| colspan="1" rowspan="1" |50 mg two to three times per day
|-
| colspan="1" rowspan="1" |Diclofenac/misoprostol (Arthrotec)
| colspan="1" rowspan="1" |50 mg/200 mcg two to three times per day
|-
| colspan="1" rowspan="1" |Ibuprofen, over-the-counter
| colspan="1" rowspan="1" |400 to 600 mg three times per day
|-
| colspan="1" rowspan="1" |Meloxicam (Mobic)
| colspan="1" rowspan="1" |7.5 to 15 mg per day
|-
| colspan="1" rowspan="1" |Nabumetone
| colspan="1" rowspan="1" |500 mg two times per day
|-
| colspan="1" rowspan="1" |Naproxen, over-the-counter (Aleve)
| colspan="1" rowspan="1" |220 to 440 mg two times per day
|-
| colspan="1" rowspan="1" |Naproxen (Naprosyn)
| colspan="1" rowspan="1" |250 to 500 mg two times per day
|-
| colspan="1" rowspan="1" |Oxaprozin (Daypro)
| colspan="1" rowspan="1" |1,200 mg per day
|-
| colspan="1" rowspan="1" |Sulindac (Clinoril)
| colspan="1" rowspan="1" |150 to 200 mg two times per day
|}


====Narcotics====
=== Corticosteroids ===
For severe pain, [[narcotic]] pain relievers such as [[tramadol]], and eventually [[opioid]]s ([[hydrocodone]], [[oxycodone]] or [[morphine]]) may be necessary; these should be reserved for very severe cases, and are rarely medically necessary for [[chronic pain]].
Cortisone are a group of man-made steroids simulating the cortisol effects in body. Cortisone injections are used for two most important reasons:
* '''I: Treatment option'''
* '''II: Diagnostic option'''


===Topical===
==== '''I: [[Osteoarthritis medical therapy|Treatment]]''' ====
"Topical treatments" are treatments designed for local application and action. Some [[NSAID]]s are available for topical use (e.g. [[ibuprofen]] and [[diclofenac]]) and may improve symptoms without having systemic side-effects.
Steroids (corticosteroid) have been used by injecting&nbsp;into the joint and reduce the inflammation, swelling, and pain in the diseased joint, for 6 weeks and 6 months period. However, studies report:
* May harm knee cartilage<ref name="pmid28510679">{{cite journal| author=McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M et al.| title=Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. | journal=JAMA | year= 2017 | volume= 317 | issue= 19 | pages= 1967-1975 | pmid=28510679 | doi=10.1001/jama.2017.5283 | pmc=5815012 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28510679  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=28975317 Review in: Ann Intern Med. 2017 Sep 19;167(6):JC27] </ref>
* Similar effectiveness to physical therapy, but more health care usage<ref name="pmid25089860">{{cite journal| author=Rhon DI, Boyles RB, Cleland JA| title=One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: a pragmatic randomized trial. | journal=Ann Intern Med | year= 2014 | volume= 161 | issue= 3 | pages= 161-9 | pmid=25089860 | doi=10.7326/M13-2199 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25089860  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25743169 Review in: Evid Based Med. 2015 Apr;20(2):67] </ref>


[[emollient|Cream]]s and [[lotion]]s, containing [[capsaicin]], are effective in treating pain associated with OA if they are applied with sufficient frequency.
==== '''II: [[Osteoarthritis diagnostic criteria|Diagnostic]]''' ====
In cases having an uncertain pain especially in hip and shoulder joints, the cortisone could be helpful in reaching accurate diagnoses. For example, if after the injection the patient's hip pain decreases, this means the pain originates from the hip. However, if the hip pain persisted after injection then other problems originating from the spine or the sacroiliac joint (the spine and pelvis) could be considered as the pain sources.


Severe pain in specific joints can be treated with local [[lidocaine]] [[Injection (medicine)|injection]]s or similar local [[anaesthetic]]s, and glucocorticoids (such as [[hydrocortisone]]). Corticosteroids (cortisone and similar agents) may temporarily reduce the pain.
=== Platelet rich plasma ===
A [[meta-analysis]] of 6 [[randomized controlled trials]] and 4 non-randomized studies through June, 2014 found benefit for osteoarthritis of the knee<ref name="pmid25416198">{{cite journal| author=Laudy AB, Bakker EW, Rekers M, Moen MH| title=Efficacy of platelet-rich plasma injections in osteoarthritis of the knee: a systematic review and meta-analysis. | journal=Br J Sports Med | year= 2015 | volume= 49 | issue= 10 | pages= 657-72 | pmid=25416198 | doi=10.1136/bjsports-2014-094036 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25416198  }} </ref>. The meta-analysis concluded only one trial<ref name="pmid22840987">{{cite journal| author=Sánchez M, Fiz N, Azofra J, Usabiaga J, Aduriz Recalde E, Garcia Gutierrez A | display-authors=etal| title=A randomized clinical trial evaluating plasma rich in growth factors (PRGF-Endoret) versus hyaluronic acid in the short-term treatment of symptomatic knee osteoarthritis. | journal=Arthroscopy | year= 2012 | volume= 28 | issue= 8 | pages= 1070-8 | pmid=22840987 | doi=10.1016/j.arthro.2012.05.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22840987  }} </ref> was not with high bias; however this trial does not report being registered.


====Prolotherapy====
A more recent [[meta-analysis]] of five [[randomized controlled trial]]s published through December, 2019 found benefit compared to hyaluronic acid<ref name="pmid32278352">{{cite journal| author=Zhao J, Huang H, Liang G, Zeng LF, Yang W, Liu J| title=Effects and safety of the combination of platelet-rich plasma (PRP) and hyaluronic acid (HA) in the treatment of knee osteoarthritis: a systematic review and meta-analysis. | journal=BMC Musculoskelet Disord | year= 2020 | volume= 21 | issue= 1 | pages= 224 | pmid=32278352 | doi=10.1186/s12891-020-03262-w | pmc=7149899 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32278352  }} </ref>. It is not clear that any of the trials were prospectively registered.
[[Prolotherapy]] (proliferative therapy); involves the injection of an irritant substance (such as dextrose) to create an acute inflammatory reaction or a proliferating substance (such as Sodium Morrhuate) to induce the body's natural wound healing cascade. It strengthens damaged tissues including ligaments, tendons and cartilage as part of this reaction. Most patients tolerate the injections without any difficulty, however they may be painful (like corticosteroids or hyaluronic acid) for a few days after wards. The only other significant risk is the rare possibility of infection.  


===Nerve Blocks===
A more recent trial, that was registered after completion, but before long term follow-up was undertaken, found no benefit compared to hyaluronic acid<ref name="pmid30545242">{{cite journal| author=Di Martino A, Di Matteo B, Papio T, Tentoni F, Selleri F, Cenacchi A | display-authors=etal| title=Platelet-Rich Plasma Versus Hyaluronic Acid Injections for the Treatment of Knee Osteoarthritis: Results at 5 Years of a Double-Blind, Randomized Controlled Trial. | journal=Am J Sports Med | year= 2019 | volume= 47 | issue= 2 | pages= 347-354 | pmid=30545242 | doi=10.1177/0363546518814532 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30545242 }} </ref>
While most people dont think of nerve blocks when treating osteoarthritis, they can provide rather dramatic pain relief while also addressing the root cause of pain. Quite frequently muscles are in spasm when arthritis is present, in order to protect a diseased joint or as a result of mechanical problems that occur due to the arthritis. In fact, quite often a nerve irritation in the back will cause tight hamstrings. That in turn reduces joint space and causes abnormalities in joint mechanics. The result is a progression, or worsening of arthritis.  The whole process can be reversed when such problems are present and addressed.


===Hyaluronidase===
=== ''Complications'' ===
Intraarticular viscosupplementation of the knee with [[hyaluronic acid]] is "associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events."<ref name="pmid16625636">{{cite journal| author=Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G| title=Intraarticular corticosteroid for treatment of osteoarthritis of the knee. | journal=Cochrane Database Syst Rev | year= 2006 | volume=  | issue= 2 | pages= CD005328 | pmid=16625636 | doi=10.1002/14651858.CD005328.pub2 | pmc= | url= }} </ref>
* The U.S. Food and Drug Administration recommends not to use more than 4,000 mg of acetaminophen/day in order to avoid its liver toxicity.
* NSAIDs could cause adverse effects such as gastrointestinal bleeding, renal dysfunction, and blood pressure elevation.
* Steroids injection has complications like breaking down the tissues, such as articular cartilage in the joint. Due to the important role of cartilage in joint system, most doctors refuse to use frequent cortisone injections in the same joint in a short period of time.


==References==
==References==

Latest revision as of 07:46, 23 May 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou[2], Irfan Dotani [3].

Overview

As all diseases, the prevention and the early diagnosis and onetime treatment of OA play important roles patient final outcome. The treatment of OA can be categorized into two options. Treatment options of OA are: Nonsurgical (non-pharmacological, pharmacological, and complementary) and surgical interventions. As it always was, is, and will be, the patients have this right to get the best, safest, and least invasive therapies as their first treatment options. Meanwhile, surgical interventions should be considered in patients who have responded to the first line non/less invasive therapies inadequately. Meanwhile, the non-surgical treatments are often effective enough as the first line in patients management. Actually, the osteoarthritis treatment is a combination of medical therapies.

Medical Therapy

Non-pharmacological

Nonpharmacologic therapy is consisted of physical therapy and specific type of physical exercises, bracing and splinting:[1][2][3]

  • Physical therapy results in short-term pain reduction, and improvement in physical function in the diseased joint to preserve its the ability for daily tasks like walking, dressing, and even bathing.
  • Walking can reduce pain from osteoarthritis. A 1997 randomized controlled trial found 1 hour of walking based aerobic activity three times per week showed, over 18 months that older people with symptomatic osteoarthritis had consistent modest improvement in self-reported pain and disability compared with participation in health education programs. Futhermore, there seemed to be some correlation between increased amount of exercise and greater improvements in pain[4].
  • On the other hand, resting is another important healing factor in OA.
  • Bracing and splinting as other methods help to support painful or unstable joints.
  • Using a cane can help decrease the weight pressure in diseased hip or knee, but it should be used on the contralateral side of the affected joint.

Analgesics

Drug therapy in OA management plays an important role in relieving pain and slow downing the progression of this disease. Meanwhile, common medications are:[5][6][7]

  • Analgesics: Including acetaminophen (e.g. Tylenol), or tramadol (e.g. Ultram) are used to reduce the pain, without any effects on inflammation or swelling. Analgesics are recommended for patients experiencing mild to moderate pain because they could cause a limited variety of side effects for patients.
  • Topical analgesics: These creams are usually used to reduce the pain in the diseased joint. They applied directly to the skin over the affected area. These creams consist of counterirritants (wintergreen and eucalyptus) which have a great effect on pain reduction. Capsaicin cream is derived from chili peppers and found to be effective in treating osteoarthritis pain, which can be applied as an adjunct therapy to the OA standard treatments. This group of therapies compared to NSAIDs had fewer adverse effects.
Medications Used for OA
Medication Typical dosage
Acetaminophen 650 to 1,000 mg four times per day
Celecoxib (Celebrex) 200 mg per day
Diclofenac sodium 50 mg two to three times per day
Diclofenac/misoprostol (Arthrotec) 50 mg/200 mcg two to three times per day
Ibuprofen, over-the-counter 400 to 600 mg three times per day
Meloxicam (Mobic) 7.5 to 15 mg per day
Nabumetone 500 mg two times per day
Naproxen, over-the-counter (Aleve) 220 to 440 mg two times per day
Naproxen (Naprosyn) 250 to 500 mg two times per day
Oxaprozin (Daypro) 1,200 mg per day
Sulindac (Clinoril) 150 to 200 mg two times per day

Corticosteroids

Cortisone are a group of man-made steroids simulating the cortisol effects in body. Cortisone injections are used for two most important reasons:

  • I: Treatment option
  • II: Diagnostic option

I: Treatment

Steroids (corticosteroid) have been used by injecting into the joint and reduce the inflammation, swelling, and pain in the diseased joint, for 6 weeks and 6 months period. However, studies report:

  • May harm knee cartilage[8]
  • Similar effectiveness to physical therapy, but more health care usage[9]

II: Diagnostic

In cases having an uncertain pain especially in hip and shoulder joints, the cortisone could be helpful in reaching accurate diagnoses. For example, if after the injection the patient's hip pain decreases, this means the pain originates from the hip. However, if the hip pain persisted after injection then other problems originating from the spine or the sacroiliac joint (the spine and pelvis) could be considered as the pain sources.

Platelet rich plasma

A meta-analysis of 6 randomized controlled trials and 4 non-randomized studies through June, 2014 found benefit for osteoarthritis of the knee[10]. The meta-analysis concluded only one trial[11] was not with high bias; however this trial does not report being registered.

A more recent meta-analysis of five randomized controlled trials published through December, 2019 found benefit compared to hyaluronic acid[12]. It is not clear that any of the trials were prospectively registered.

A more recent trial, that was registered after completion, but before long term follow-up was undertaken, found no benefit compared to hyaluronic acid[13]

Complications

  • The U.S. Food and Drug Administration recommends not to use more than 4,000 mg of acetaminophen/day in order to avoid its liver toxicity.
  • NSAIDs could cause adverse effects such as gastrointestinal bleeding, renal dysfunction, and blood pressure elevation.
  • Steroids injection has complications like breaking down the tissues, such as articular cartilage in the joint. Due to the important role of cartilage in joint system, most doctors refuse to use frequent cortisone injections in the same joint in a short period of time.

References

  1. ↑ Lauche R, Cramer H, Langhorst J, Dobos G (January 2014). "A systematic review and meta-analysis of medical leech therapy for osteoarthritis of the knee". Clin J Pain. 30 (1): 63–72. doi:10.1097/AJP.0b013e31828440ce. PMID 23446069.
  2. ↑ Lauche R, Langhorst J, Dobos G, Cramer H (August 2013). "A systematic review and meta-analysis of Tai Chi for osteoarthritis of the knee". Complement Ther Med. 21 (4): 396–406. doi:10.1016/j.ctim.2013.06.001. PMID 23876571.
  3. ↑ Zhang Y, Huang L, Su Y, Zhan Z, Li Y, Lai X (2017). "The Effects of Traditional Chinese Exercise in Treating Knee Osteoarthritis: A Systematic Review and Meta-Analysis". PLoS ONE. 12 (1): e0170237. doi:10.1371/journal.pone.0170237. PMC 5266306. PMID 28121996.
  4. ↑ Ettinger WH, Burns R, Messier SP, Applegate W, Rejeski WJ, Morgan T; et al. (1997). "A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST)". JAMA. 277 (1): 25–31. PMID 8980206.
  5. ↑ Watson M, Brookes ST, Faulkner A, Kirwan J (July 2007). "WITHDRAWN: Non-aspirin, non-steroidal anti-inflammatory drugs for treating osteoarthritis of the knee". Cochrane Database Syst Rev (1): CD000142. doi:10.1002/14651858.CD000142.pub2. PMID 17636601.
  6. ↑ Towheed TE, Maxwell L, Anastassiades TP, Shea B, Houpt J, Robinson V, Hochberg MC, Wells G (April 2005). "Glucosamine therapy for treating osteoarthritis". Cochrane Database Syst Rev (2): CD002946. doi:10.1002/14651858.CD002946.pub2. PMID 15846645.
  7. ↑ Towheed TE, Maxwell L, Judd MG, Catton M, Hochberg MC, Wells G (January 2006). "Acetaminophen for osteoarthritis". Cochrane Database Syst Rev (1): CD004257. doi:10.1002/14651858.CD004257.pub2. PMID 16437479.
  8. ↑ McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M; et al. (2017). "Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial". JAMA. 317 (19): 1967–1975. doi:10.1001/jama.2017.5283. PMC 5815012. PMID 28510679. Review in: Ann Intern Med. 2017 Sep 19;167(6):JC27
  9. ↑ Rhon DI, Boyles RB, Cleland JA (2014). "One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: a pragmatic randomized trial". Ann Intern Med. 161 (3): 161–9. doi:10.7326/M13-2199. PMID 25089860. Review in: Evid Based Med. 2015 Apr;20(2):67
  10. ↑ Laudy AB, Bakker EW, Rekers M, Moen MH (2015). "Efficacy of platelet-rich plasma injections in osteoarthritis of the knee: a systematic review and meta-analysis". Br J Sports Med. 49 (10): 657–72. doi:10.1136/bjsports-2014-094036. PMID 25416198.
  11. ↑ Sánchez M, Fiz N, Azofra J, Usabiaga J, Aduriz Recalde E, Garcia Gutierrez A; et al. (2012). "A randomized clinical trial evaluating plasma rich in growth factors (PRGF-Endoret) versus hyaluronic acid in the short-term treatment of symptomatic knee osteoarthritis". Arthroscopy. 28 (8): 1070–8. doi:10.1016/j.arthro.2012.05.011. PMID 22840987.
  12. ↑ Zhao J, Huang H, Liang G, Zeng LF, Yang W, Liu J (2020). "Effects and safety of the combination of platelet-rich plasma (PRP) and hyaluronic acid (HA) in the treatment of knee osteoarthritis: a systematic review and meta-analysis". BMC Musculoskelet Disord. 21 (1): 224. doi:10.1186/s12891-020-03262-w. PMC 7149899 Check |pmc= value (help). PMID 32278352 Check |pmid= value (help).
  13. ↑ Di Martino A, Di Matteo B, Papio T, Tentoni F, Selleri F, Cenacchi A; et al. (2019). "Platelet-Rich Plasma Versus Hyaluronic Acid Injections for the Treatment of Knee Osteoarthritis: Results at 5 Years of a Double-Blind, Randomized Controlled Trial". Am J Sports Med. 47 (2): 347–354. doi:10.1177/0363546518814532. PMID 30545242.

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