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Managing osteoarthritis: What’s best for your patient?

Practice recommendation

  • Teach patients that self-care is key to successful management of osteoarthritis (Osteoarthritis Research Society International [OARSI] Evidence 1a
  • Encourage patients to regularly engage in aerobic, muscle-strengthening, and range-of-motion exercise (Ia: knee; IV: hip).
  • Recommend that patients try acetaminophen (≤4 g/d) before considering other analgesics for mild to moderate joint pain (Ia: knee; IV: hip).
  • Prescribe the lowest effective dose of nonsteroidal anti-inflammatory drugs (NSAIDs) and avoid using them for long-term therapy (Ia).

OARSI level of evidence:

Ia: Meta-analysis of randomized controlled trials (RCTs)
Ib: RCT
IIa: Controlled study without randomization
IIb: Quasi-experimental study
III: Nonexperimental, descriptive studies
IV: Expert committee reports/opinion/experience

Osteoarthritis (OA) and other rheumatic conditions account for as many office visits as cardiovascular disease or essential hypertension, according to national data, and most involve primary care physicians.1 As the population ages, the prevalence of OA—estimated at 46.4 million in 2005 in the United States alone—will continue to rise.2,3 So, too, will the number of patients needing treatment for pain and functional limitations related to OA of the hips and knees.

Physicians who treat these patients have a new tool at their disposal: the Osteoarthritis Research Society International (OARSI)’s evidence-based, expert consensus guidelines for the management of hip and knee OA. These recommendations, published in February 2008, are the first “internationally agreed and universally applicable guidelines for the management of these global disorders.”4

In caring for patients with OA of the hips or knees, family physicians should keep in mind 2 guiding principles at the heart of the OARSI recommendations:

  • the importance of lifestyle modification, including regular exercise, in coping with this degenerative, potentially debilitating disease; and
  • the need to incorporate both nonpharmacologic interventions and drug therapy to achieve optimal care.4

International team sifts through the evidence

To develop the guidelines, OARSI convened a committee of 16 physicians from 6 countries and 2 continents, with expertise in 4 disciplines: rheumatology, orthopedics, evidence-based medicine, and primary care. The team reviewed national and regional guidelines and studied systematic reviews; meta-analyses; randomized controlled trials (RCTs); controlled and uncontrolled trials; cohort, case-control, and cross-sectional studies; and economic evaluations from 1945 through 2001. The team also conducted a systematic review of evidence from January 2002 through January 2006.4,5 To ensure the quality of evidence hierarchy, the team used internationally accepted research tools.

AP and tunnel images are key to OA diagnosis

A diagnosis of knee or hip osteoarthritis (OA) requires a medical history; physical examination; radiologic assessment, with standing X-rays of the lower extremities, including anterior-posterior and tunnel views for knee OA; and the exclusion of other conditions.30 The tunnel view shown here reveals bone-on-bone articulation in the medial compartment of the left knee, and demonstrates the importance of standing X-rays.

Differential diagnosis includes gout, pseudogout, rheumatoid arthritis, patella-femoral pain, pes anserine (knee) bursitis, iliotibial band pathology, meniscal tear, cruciate tears, and tumors. No blood tests are indicated unless an inflammatory process is suspected. Synovial fluid in an osteoarthritic knee has a white cell count of <2000/uL.31

The team used several criteria to rate the recommended strategies, including level of evidence, effect size for pain relief, level of consensus, and strength of recommendation (SOR). All of these criteria are included (and defined) in an at-a-glance summary of the OARSI recommendations ( TABLE ).

In particular, the SOR, which is used throughout this article, is an overall rating that reflects the opinions of the team members after consideration of the research evidence for efficacy, safety, and cost-effectiveness. It is based on a visual analog scale of 0 to 100 mm and is expressed as a percentage.

TABLE
OARSI guidelines rate the evidence for osteoarthritis treatment options

RECOMMENDATION SOR, % (95% CI)*/ LEVEL OF CONSENSUS, % LEVEL OF EVIDENCE ES (95% CI)§
Nonpharmacologic
Education, self-help, patient-driven treatment97 (95 to 99)/NAIa: educationNA
Aerobic, muscle-strengthening, and range-of-motion exercises96 (93 to 99)/85Ia: knee
IV: hip
Ib: hip, water-based
0.52 (0.34 to 0.70): aerobic
0.32 (0.23 to 0.42): strength
0.25 (0.02 to 0.47): water-based
Weight loss96 (92 to 100)/100Ia0.13 (-0.12 to 0.38)
Walking aids90 (84 to 96)/100IVNA
Physical therapy89 (82 to 96)/100IVNA
Appropriate footwear/insoles77 (66 to 88)/92IV: footwear
Ia: insoles
NA
Knee braces76 (69 to 83)/92IaNA
Telephone contact66 (57 to 75)/77Ia: knee; IV: hip0.12 (0 to 0.24)
Thermal modalities64 (60 to 68)/77Ia0.69 (-0.07 to 1.45)
Acupuncture59 (47 to 71)/69Ia0.51 (0.23 to 0.79)
TENS58 (45 to 72)/69IaNA
Pharmacologic
Oral NSAIDs93 (88 to 99)/100Ia0.32 (0.24 to 0.39)
Acetaminophen ≤4 g/d92 (88 to 99)/77Ia: knee; IV: hip0.21 (0.02 to 0.41)
Topical NSAIDs/capsaicin85 (75 to 95)/100Ia0.41 (0.22 to 0.59)
Weak opioids/narcotics82 (74 to 90)/92IaNA
IA corticosteroid injections78 (61 to 95)/69Ia: knee; Ib: hip0.72 (0.42 to 1.02)
IA hyaluronate injections64 (43 to 85)/85Ia0.32 (0.17 to 0.47)
Glucosamine and/or chondroitin63 (44 to 82)/92Ia: glucosamine0.45 (0.04 to 0.86)
Surgical treatments
Joint replacement96 (94 to 98)/92IIINA
Unicompartmental knee replacement76 (64 to 88)/100IIIbNA
Osteotomy/joint preservation75 (64 to 86)/100IIbNA
Joint fusion69 (57 to 82)/100IVNA
Joint lavage/arthroscopic debridement60 (47 to 82)/100Ib0.09 (-0.27 to 0.44): lavage
-0.01 (-0.37 to 0.35): debridement
CI, confidence interval; ES, effect size for pain relief; IA, intraarticular; NA, not available; NSAIDs, nonsteroidal anti-inflammatory drugs; OARSI, Osteoarthritis Research Society International; SOR, strength of recommendation; TENS, transcutaneous electrical nerve stimulation
* SOR (strength of recommendation) is an overall rating that reflects the opinions of OARSI team members after consideration of the research evidence for efficacy, safety, and cost-effectiveness. SOR is based on a visual analog scale of 0 to 100 mm and is expressed as a percentage.
Level of consensus is the estimated extent of agreement among committee members, expressed as a percentage.
Level of evidence is broken into 6 categories: Ia: meta-analysis of randomized controlled trials (RCTs); Ib: RCT; IIa: controlled study without randomization; IIb: quasi-experimental study; III: nonexperimental, descriptive studies; and IV: expert committee reports/opinion/experience.
§ES (effect size for pain relief) is a measure of the standard mean difference between interventions (eg, treatment vs placebo): 0.2 (small); 0.5 (moderate); and >0.8 (large). The ES refers to the knee and hip unless otherwise specified.
Adapted from: Zhang et al.4
 

 

OARSI emphasizes patient education

Patient education about self-care and lifestyle modifications, such as weight loss, exercise, and pacing of activities to reduce the load on the affected joints, is OARSI’s strongest nonpharmacologic recommendation (SOR: 97%). The guidelines also call for the following interventions:

  • correcting mechanical abnormalities of the skeleton;
  • helping patients lose weight;
  • assisting patients with smoking cessation efforts;6
  • directing the use of nonprescription medications;
  • prescribing assistive devices; and
  • prescribing appropriate prescription drugs.

Nondrug options: Exercise that achy joint

To many patients, being told to exercise a joint in which movement is associated with stiffness and bone-on-bone pain seems counterintuitive. Referring to the findings of the OARSI panel may be helpful in explaining the importance of regular aerobic, muscle-strengthening, and range-of-motion exercises, all of which are strongly recommended (SOR: 96%). Exercise can be as simple as “regular aerobic walking” and home-based strengthening of the quadriceps.4 For patients with arthritic hips, water-based exercises are recommended.

Obesity can increase the risk of developing OA of the hips and knees, and excess weight puts extra stress on joints that are already arthritic. Thus, weight loss is both a risk modification factor (see “Is your patient at risk of OA? Take steps now” ) and a key OA management strategy (SOR: 96%). In a meta-regression analysis conducted by the committee, a reduction of >5% of body weight or a loss at a rate of >0.24% per week was associated with significant improvement in disability. One RCT had a number needed to treat (NNT) of 3 (95% confidence interval [CI], 2-9) to achieve improved pain and function scores after a 2-month low-energy diet.7

Is your patient at risk of OA? Take steps now

Risk factors for osteoarthritis (OA) include:14-19

  • mechanical abnormalities, such as varus (bowlegged) and valgus (knock-kneed) angulations;
  • flat feet, and heel pronation and supination;
  • a history of joint surgery or acute injuries, particularly to the anterior cruciate ligament (ACL) or meniscus;
  • obesity;
  • manual labor (any job that involves heavy lifting, together with kneeling and squatting);
  • participation in competitive or high-intensity sports; and
  • a family history of OA (based on mounting evidence of a genetic link).20-22

Lack of neuromuscular control (proprioception) of the knee is another risk factor, since it can expose the internal joint to forces that would otherwise be absorbed by muscle. Exposure of the joint to excess forces can occur if the impact is rapid, leaving the muscle without adequate time to contract to absorb the force, or the muscle is fatigued and weak from prolonged exercise.23,24

Work with patients to modify risk. In discussing risk modification with patients, emphasize that high-intensity running, especially when practiced for years, increases the risk of OA of the knees.25 Indeed, high-impact activity of any kind subjects knee cartilage to significant single and repetitive impact loads and torsional loads.17,26 Point out, however, that some physical activity is needed to maintain normal metabolic activity of cartilage in a healthy joint and that recreational, mild-intensity running or jogging does not appear to increase the risk for OA.27

Be aggressive with knee injuries. As noted earlier, a history of acute ACL or meniscus injury is a risk factor for OA. Knee trauma with effusions that develop rapidly (within 2-12 hours) is associated with high risk of significant intraarticular damage to the ACL, meniscus, and articular cartilage.28 A study of pediatric and adolescent patients who underwent magnetic resonance imaging for possible internal knee injury found cartilage injuries to be the most common.29

To avoid additional damage, manage knee trauma with effusions as a significant injury. Treatment includes bracing, physical therapy, low-impact exercise, and possibly even cross-training or job modification. Advise patients to continue physical therapy until strength and proprioception are fully recovered and no pain or effusion remains, which generally takes about 6 to 8 weeks, and not to return to normal activity prematurely.

Don’t underestimate the power of a phone call

Other nonpharmacologic recommendations include referral to a physical therapist for evaluation and exercise instruction (SOR: 89%); instruction in the use of walking aids, such as a cane or crutch in the contralateral hand, to improve biomechanics (SOR: 90%); and the use of braces to support unstable knees, an unproven intervention that may increase proprioception and stability (SOR: 76%). Physicians should also recommend footwear with insoles or lateral wedges to decrease lateral thrust of the knee and medial compartment forces (SOR: 77%).

Regular telephone contact, possibly on a monthly basis, is a suggested strategy for promoting self-care, tested in patients with OA of the knee but recommended for those with arthritic hips solely on the basis of expert opinion. A number of other modalities, including thermal therapy (heat treatments with warm water or wax, or cold therapy with a 20-minute ice massage), transcutaneous electrical nerve stimulation (TENS), and acupuncture, are recommended for symptom relief.

 

 

Drug therapy: Start with acetaminophen

The OARSI guidelines cite acetaminophen as an “effective initial oral analgesic” for mild to moderate pain in patients with OA of the hips or knees (SOR: 92%).4 In analyses conducted by the committee, the NNT to achieve an improvement in pain ranged from 1 to 2 in an earlier systematic review8 to 4 to 16 in a subsequent meta-analysis.9

Prescribe NSAIDs for short-term relief. While acetaminophen is considered the preferred long-term oral treatment, the strongest pharmacologic recommendation for alleviating the pain and stiffness associated with OA of the hip or knee is for nonsteroidal anti-inflammatory drugs (NSAIDs) (SOR: 93%). The caveat, however, is that NSAIDs should be used in the lowest effective dose and are not considered a long-term option. Patients with increased gastrointestinal (GI) risk should use either a cyclooxygenase-2 (COX-2) agent or an NSAID with a proton pump inhibitor or misoprostol for GI protection.

For those with cardiovascular risks, both nonselective NSAIDs and COX-2 agents require caution; here, too, the lowest dose for the shortest possible duration is recommended.

The guidelines also call for the use of topical agents, such as topical NSAIDs and capsaicin, for relief of symptoms (SOR: 85%). The NNT for topical NSAIDs was 3 (95% CI, 2-4);4 capsaicin had an NNT of 4 (95% CI, 3-5) after 4 weeks of therapy.4 The recommendations also note that glucosamine and/or chondroitin sulfate may alleviate some symptoms of osteoarthritis of the knee, but should be discontinued if no benefit is observed after 6 months.

When something stronger is needed. For moderate to severe pain that has not responded to oral agents, intraarticular (IA) injections with corticosteroids are recommended, as are IA hyaluronate injections (SOR: 78% and 64%, respectively). Weak opioids/low-dose narcotics round out the recommendations for treating moderate pain, with stronger opioids reserved for patients whose pain is severe.

When to consider surgery

Joint replacement surgery is recommended for patients who do not achieve adequate pain relief and functional improvement from nonpharmacologic and pharmacologic modalities (SOR: 96%). A meta-analysis of 74 studies assessing quality of life 1 to 7 years after total hip and total knee replacement (THR and TKR) found substantial improvement in pain and function, but variable effects on mental health and social functioning. Risk factors for poor outcomes include older age; more (or more severe) preoperative pain; medical comorbidities; musculoskeletal comorbidities such as low back pain, with functional limitations; low mental health scores; and OA in the hip that was not replaced.10,11

Unicompartmental knee replacement (UKR) had an SOR of 76%. Reviews that compared TKR to UKR found similar 5-year outcomes in knee pain and function. Those who underwent UKR had better range of motion, but prosthesis survival at 10 years was better in those with TKR (>90% vs 85% to 90%).12

In young adults, osteotomy and jointpreserving procedures are recommended for hip OA, especially when dysplasia is present. In young, active patients with unicompartment OA, high tibial osteotomies may delay TKR by as long as 10 years.13

Joint lavage and arthroscopic debridement in knee OA remain controversial, although they may provide short-term symptom relief (SOR: 60%). Joint fusion as a salvage procedure after failed TKR had an SOR of 69%.

Work as a team to improve outcomes

The inevitable increase in the number of patients with OA of the hips and knees underscores the importance of having a range of treatment strategies, often best delivered by a multidisciplinary team with the family physician at the helm. The OARSI guidelines, which are backed by both a thorough review of research findings and expert consensus, can help you convince patients to take an active role in managing this potentially debilitating condition. Patients’ commitment to lifestyle modifications and self-management, bolstered by your guidance and support, is the most effective way to keep patients with OA on the move.

Correspondence
Greg P. Gutierrez, MD, Associate Professor, University of Colorado Denver Health Sciences Center, Department of Family Medicine, Denver Health and Hospital, 660 Bannock St., Denver, CO 80218; [email protected].

References

1. Hootman JM. Magnitude and characteristics of arthritis and other rheumatic conditions on ambulatory medical care visits, United States, 1997. Arthritis Rheum. 2002;47:571-581.

2. Lawrence R, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. 1998;41:778-799.

3. US Department of Health and Human Services. CDC: prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation - United States, 2003–2005. MMWR. 2006;55:1089-1092.

4. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-162.

5. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartilage. 2007;15:981-1000.

6. Amin S, Niu J, Guermazi A, et al. Cigarette smoking and the risk for cartilage loss and knee pain in men with knee osteoarthritis. Ann Rheum Dis. 2007;66:18-22.

7. Christensen R, Astrup A, Bliddal H. Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial. Osteoarthritis Cartilage. 2005;13:20-27.

8. Towheed TE, Hochberg MC, Judd MG, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2003;(2):CD004257.-

9. Towheed TE, Maxwell L, Judd MG, Catton M, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2006;(1):CD004257.-

10. Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am. 2004;86-A:963-974.

11. Lingard EA, Katz JN, Wright EA, Sledge CB. Kinemax Outcomes Group. Predicting the outcome of total knee arthroplasty. J Bone Joint Surg Am. 2004;86-A:2179-2186.

12. Griffin T, Rowden L, Morgan D, Atkinson R, Woodruff P, Madden G. Unicompartmental knee arthroplasty for the treatment of unicompartmental osteoarthritis: a systematic study. ANZ J Surg. 2007;77:214-221.

13. Virolainen P, Arc HT. High tibial osteotomy for the treatment of osteoarthritis of the knee: a review of the literature and a meta-analysis of follow-up studies. Arch Orthop Trauma Surg. 2004;124:258-261.

14. Felson DT. Relation of obesity and of vocational and avocational risk factors to osteoarthritis. J Rheumatol. 2005;32:1133-1135.

15. Gelber AC, Hochberg MC, Mead LA, Wang NY, Wigley FM, Klag MJ. Joint injury in young adults and risk for subsequent knee and hip osteoarthritis. Ann Intern Med. 2000;133:321-328.

16. Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD. The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA. 2001;286:188-195.

17. Lequesne MG, Dang N, Lane NE. Sport practice and osteoarthritis of the limbs. Osteoarthritis Cartilage. 1997;5:75-86.

18. Griffin TM, Guilak F. The role of mechanical loading in the onset and progression of osteoarthritis. Exerc Sport Sci Rev. 2005;33:195-200.

19. Maetzel A, Makela M, Hawker G, Bombardier C. Osteoarthritis of the hip and knee and mechanical occupational exposure: a systematic overview of the evidence. J Rheumatol. 1997;24:1599-1607.

20. Zhai G, Ding C, Stankovich J, Cicuttini F, Jones G. The genetic contribution to longitudinal changes in knee structure and muscle strength: a sibpair study. Arthritis Rheum. 2005;52:2830-2834.

21. Hirsch R, Lethbridge-Cejku M, Hanson R, et al. Familial aggregation of osteoarthritis: data from the Baltimore Longitudinal Study on Aging. Arthritis Rheum. 1998;41:1227-1232.

22. Felson DT, Couropmitree NN, Chaisson CE, et al. Evidence for a Mendelian gene in a segregation analysis of generalized radiographic osteoarthritis: the Framingham Study. Arthritis Rheum. 1998;41:1064-1071.

23. Christina KA, White SC, Gilchrist LA. Effect of localized muscle fatigue on vertical ground reaction forces and ankle joint motion during running. Hum Mov Sci. 2001;20:257-276.

24. Mizrahi J, Verbitsky O, Isakov E. Fatigue-related loading imbalance on the shank in running: a possible factor in stress fractures. Ann Biomed Eng. 2000;28:463-469.

25. McAlindon TE, Wilson PW, Aliabadi P, Weissman B, Felson DT. Level of physical activity and the risk of radiographic and symptomatic knee osteoarthritis in the elderly: the Framingham study. Am J Med. 1999;106:151-157.

26. Buckwalter JA. Sports, joint injury, and posttraumatic osteoarthritis. J Orthop Sports Phys Ther. 2003;33:578-588.

27. Conaghan PG. Update on osteoarthritis part 1: current concepts and the relation to exercise. British J Sports Med. 2002;36:330-333.

28. Maffulli N, Binfield PM, King JB, Good CJ. Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases. J Bone Joint Surg Br. 1993;75:945-949.

29. Oeppen RS, Connolly SA, Bencardino JT, Jaramillo D. Acute injury of the articular cartilage and subchondral bone: a common but unrecognized lesion in the immature knee. Am J Roentgenol. 2004;182:111-117.

30. Felson DT. Osteoarthritis of the knee. N Engl J Med. 2006;354:841-848.

31. Hassebacher B. Arthrocentesis, synovial fluid analysis and synovial biopsy. In: Schumacher HR, Klippel JH, Koopman WJ, eds. Primer on the Rheumatic Diseases. Atlanta, GA: Arthritis Foundation; 1993:67-72.

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Practice recommendation

  • Teach patients that self-care is key to successful management of osteoarthritis (Osteoarthritis Research Society International [OARSI] Evidence 1a
  • Encourage patients to regularly engage in aerobic, muscle-strengthening, and range-of-motion exercise (Ia: knee; IV: hip).
  • Recommend that patients try acetaminophen (≤4 g/d) before considering other analgesics for mild to moderate joint pain (Ia: knee; IV: hip).
  • Prescribe the lowest effective dose of nonsteroidal anti-inflammatory drugs (NSAIDs) and avoid using them for long-term therapy (Ia).

OARSI level of evidence:

Ia: Meta-analysis of randomized controlled trials (RCTs)
Ib: RCT
IIa: Controlled study without randomization
IIb: Quasi-experimental study
III: Nonexperimental, descriptive studies
IV: Expert committee reports/opinion/experience

Osteoarthritis (OA) and other rheumatic conditions account for as many office visits as cardiovascular disease or essential hypertension, according to national data, and most involve primary care physicians.1 As the population ages, the prevalence of OA—estimated at 46.4 million in 2005 in the United States alone—will continue to rise.2,3 So, too, will the number of patients needing treatment for pain and functional limitations related to OA of the hips and knees.

Physicians who treat these patients have a new tool at their disposal: the Osteoarthritis Research Society International (OARSI)’s evidence-based, expert consensus guidelines for the management of hip and knee OA. These recommendations, published in February 2008, are the first “internationally agreed and universally applicable guidelines for the management of these global disorders.”4

In caring for patients with OA of the hips or knees, family physicians should keep in mind 2 guiding principles at the heart of the OARSI recommendations:

  • the importance of lifestyle modification, including regular exercise, in coping with this degenerative, potentially debilitating disease; and
  • the need to incorporate both nonpharmacologic interventions and drug therapy to achieve optimal care.4

International team sifts through the evidence

To develop the guidelines, OARSI convened a committee of 16 physicians from 6 countries and 2 continents, with expertise in 4 disciplines: rheumatology, orthopedics, evidence-based medicine, and primary care. The team reviewed national and regional guidelines and studied systematic reviews; meta-analyses; randomized controlled trials (RCTs); controlled and uncontrolled trials; cohort, case-control, and cross-sectional studies; and economic evaluations from 1945 through 2001. The team also conducted a systematic review of evidence from January 2002 through January 2006.4,5 To ensure the quality of evidence hierarchy, the team used internationally accepted research tools.

AP and tunnel images are key to OA diagnosis

A diagnosis of knee or hip osteoarthritis (OA) requires a medical history; physical examination; radiologic assessment, with standing X-rays of the lower extremities, including anterior-posterior and tunnel views for knee OA; and the exclusion of other conditions.30 The tunnel view shown here reveals bone-on-bone articulation in the medial compartment of the left knee, and demonstrates the importance of standing X-rays.

Differential diagnosis includes gout, pseudogout, rheumatoid arthritis, patella-femoral pain, pes anserine (knee) bursitis, iliotibial band pathology, meniscal tear, cruciate tears, and tumors. No blood tests are indicated unless an inflammatory process is suspected. Synovial fluid in an osteoarthritic knee has a white cell count of <2000/uL.31

The team used several criteria to rate the recommended strategies, including level of evidence, effect size for pain relief, level of consensus, and strength of recommendation (SOR). All of these criteria are included (and defined) in an at-a-glance summary of the OARSI recommendations ( TABLE ).

In particular, the SOR, which is used throughout this article, is an overall rating that reflects the opinions of the team members after consideration of the research evidence for efficacy, safety, and cost-effectiveness. It is based on a visual analog scale of 0 to 100 mm and is expressed as a percentage.

TABLE
OARSI guidelines rate the evidence for osteoarthritis treatment options

RECOMMENDATION SOR, % (95% CI)*/ LEVEL OF CONSENSUS, % LEVEL OF EVIDENCE ES (95% CI)§
Nonpharmacologic
Education, self-help, patient-driven treatment97 (95 to 99)/NAIa: educationNA
Aerobic, muscle-strengthening, and range-of-motion exercises96 (93 to 99)/85Ia: knee
IV: hip
Ib: hip, water-based
0.52 (0.34 to 0.70): aerobic
0.32 (0.23 to 0.42): strength
0.25 (0.02 to 0.47): water-based
Weight loss96 (92 to 100)/100Ia0.13 (-0.12 to 0.38)
Walking aids90 (84 to 96)/100IVNA
Physical therapy89 (82 to 96)/100IVNA
Appropriate footwear/insoles77 (66 to 88)/92IV: footwear
Ia: insoles
NA
Knee braces76 (69 to 83)/92IaNA
Telephone contact66 (57 to 75)/77Ia: knee; IV: hip0.12 (0 to 0.24)
Thermal modalities64 (60 to 68)/77Ia0.69 (-0.07 to 1.45)
Acupuncture59 (47 to 71)/69Ia0.51 (0.23 to 0.79)
TENS58 (45 to 72)/69IaNA
Pharmacologic
Oral NSAIDs93 (88 to 99)/100Ia0.32 (0.24 to 0.39)
Acetaminophen ≤4 g/d92 (88 to 99)/77Ia: knee; IV: hip0.21 (0.02 to 0.41)
Topical NSAIDs/capsaicin85 (75 to 95)/100Ia0.41 (0.22 to 0.59)
Weak opioids/narcotics82 (74 to 90)/92IaNA
IA corticosteroid injections78 (61 to 95)/69Ia: knee; Ib: hip0.72 (0.42 to 1.02)
IA hyaluronate injections64 (43 to 85)/85Ia0.32 (0.17 to 0.47)
Glucosamine and/or chondroitin63 (44 to 82)/92Ia: glucosamine0.45 (0.04 to 0.86)
Surgical treatments
Joint replacement96 (94 to 98)/92IIINA
Unicompartmental knee replacement76 (64 to 88)/100IIIbNA
Osteotomy/joint preservation75 (64 to 86)/100IIbNA
Joint fusion69 (57 to 82)/100IVNA
Joint lavage/arthroscopic debridement60 (47 to 82)/100Ib0.09 (-0.27 to 0.44): lavage
-0.01 (-0.37 to 0.35): debridement
CI, confidence interval; ES, effect size for pain relief; IA, intraarticular; NA, not available; NSAIDs, nonsteroidal anti-inflammatory drugs; OARSI, Osteoarthritis Research Society International; SOR, strength of recommendation; TENS, transcutaneous electrical nerve stimulation
* SOR (strength of recommendation) is an overall rating that reflects the opinions of OARSI team members after consideration of the research evidence for efficacy, safety, and cost-effectiveness. SOR is based on a visual analog scale of 0 to 100 mm and is expressed as a percentage.
Level of consensus is the estimated extent of agreement among committee members, expressed as a percentage.
Level of evidence is broken into 6 categories: Ia: meta-analysis of randomized controlled trials (RCTs); Ib: RCT; IIa: controlled study without randomization; IIb: quasi-experimental study; III: nonexperimental, descriptive studies; and IV: expert committee reports/opinion/experience.
§ES (effect size for pain relief) is a measure of the standard mean difference between interventions (eg, treatment vs placebo): 0.2 (small); 0.5 (moderate); and >0.8 (large). The ES refers to the knee and hip unless otherwise specified.
Adapted from: Zhang et al.4
 

 

OARSI emphasizes patient education

Patient education about self-care and lifestyle modifications, such as weight loss, exercise, and pacing of activities to reduce the load on the affected joints, is OARSI’s strongest nonpharmacologic recommendation (SOR: 97%). The guidelines also call for the following interventions:

  • correcting mechanical abnormalities of the skeleton;
  • helping patients lose weight;
  • assisting patients with smoking cessation efforts;6
  • directing the use of nonprescription medications;
  • prescribing assistive devices; and
  • prescribing appropriate prescription drugs.

Nondrug options: Exercise that achy joint

To many patients, being told to exercise a joint in which movement is associated with stiffness and bone-on-bone pain seems counterintuitive. Referring to the findings of the OARSI panel may be helpful in explaining the importance of regular aerobic, muscle-strengthening, and range-of-motion exercises, all of which are strongly recommended (SOR: 96%). Exercise can be as simple as “regular aerobic walking” and home-based strengthening of the quadriceps.4 For patients with arthritic hips, water-based exercises are recommended.

Obesity can increase the risk of developing OA of the hips and knees, and excess weight puts extra stress on joints that are already arthritic. Thus, weight loss is both a risk modification factor (see “Is your patient at risk of OA? Take steps now” ) and a key OA management strategy (SOR: 96%). In a meta-regression analysis conducted by the committee, a reduction of >5% of body weight or a loss at a rate of >0.24% per week was associated with significant improvement in disability. One RCT had a number needed to treat (NNT) of 3 (95% confidence interval [CI], 2-9) to achieve improved pain and function scores after a 2-month low-energy diet.7

Is your patient at risk of OA? Take steps now

Risk factors for osteoarthritis (OA) include:14-19

  • mechanical abnormalities, such as varus (bowlegged) and valgus (knock-kneed) angulations;
  • flat feet, and heel pronation and supination;
  • a history of joint surgery or acute injuries, particularly to the anterior cruciate ligament (ACL) or meniscus;
  • obesity;
  • manual labor (any job that involves heavy lifting, together with kneeling and squatting);
  • participation in competitive or high-intensity sports; and
  • a family history of OA (based on mounting evidence of a genetic link).20-22

Lack of neuromuscular control (proprioception) of the knee is another risk factor, since it can expose the internal joint to forces that would otherwise be absorbed by muscle. Exposure of the joint to excess forces can occur if the impact is rapid, leaving the muscle without adequate time to contract to absorb the force, or the muscle is fatigued and weak from prolonged exercise.23,24

Work with patients to modify risk. In discussing risk modification with patients, emphasize that high-intensity running, especially when practiced for years, increases the risk of OA of the knees.25 Indeed, high-impact activity of any kind subjects knee cartilage to significant single and repetitive impact loads and torsional loads.17,26 Point out, however, that some physical activity is needed to maintain normal metabolic activity of cartilage in a healthy joint and that recreational, mild-intensity running or jogging does not appear to increase the risk for OA.27

Be aggressive with knee injuries. As noted earlier, a history of acute ACL or meniscus injury is a risk factor for OA. Knee trauma with effusions that develop rapidly (within 2-12 hours) is associated with high risk of significant intraarticular damage to the ACL, meniscus, and articular cartilage.28 A study of pediatric and adolescent patients who underwent magnetic resonance imaging for possible internal knee injury found cartilage injuries to be the most common.29

To avoid additional damage, manage knee trauma with effusions as a significant injury. Treatment includes bracing, physical therapy, low-impact exercise, and possibly even cross-training or job modification. Advise patients to continue physical therapy until strength and proprioception are fully recovered and no pain or effusion remains, which generally takes about 6 to 8 weeks, and not to return to normal activity prematurely.

Don’t underestimate the power of a phone call

Other nonpharmacologic recommendations include referral to a physical therapist for evaluation and exercise instruction (SOR: 89%); instruction in the use of walking aids, such as a cane or crutch in the contralateral hand, to improve biomechanics (SOR: 90%); and the use of braces to support unstable knees, an unproven intervention that may increase proprioception and stability (SOR: 76%). Physicians should also recommend footwear with insoles or lateral wedges to decrease lateral thrust of the knee and medial compartment forces (SOR: 77%).

Regular telephone contact, possibly on a monthly basis, is a suggested strategy for promoting self-care, tested in patients with OA of the knee but recommended for those with arthritic hips solely on the basis of expert opinion. A number of other modalities, including thermal therapy (heat treatments with warm water or wax, or cold therapy with a 20-minute ice massage), transcutaneous electrical nerve stimulation (TENS), and acupuncture, are recommended for symptom relief.

 

 

Drug therapy: Start with acetaminophen

The OARSI guidelines cite acetaminophen as an “effective initial oral analgesic” for mild to moderate pain in patients with OA of the hips or knees (SOR: 92%).4 In analyses conducted by the committee, the NNT to achieve an improvement in pain ranged from 1 to 2 in an earlier systematic review8 to 4 to 16 in a subsequent meta-analysis.9

Prescribe NSAIDs for short-term relief. While acetaminophen is considered the preferred long-term oral treatment, the strongest pharmacologic recommendation for alleviating the pain and stiffness associated with OA of the hip or knee is for nonsteroidal anti-inflammatory drugs (NSAIDs) (SOR: 93%). The caveat, however, is that NSAIDs should be used in the lowest effective dose and are not considered a long-term option. Patients with increased gastrointestinal (GI) risk should use either a cyclooxygenase-2 (COX-2) agent or an NSAID with a proton pump inhibitor or misoprostol for GI protection.

For those with cardiovascular risks, both nonselective NSAIDs and COX-2 agents require caution; here, too, the lowest dose for the shortest possible duration is recommended.

The guidelines also call for the use of topical agents, such as topical NSAIDs and capsaicin, for relief of symptoms (SOR: 85%). The NNT for topical NSAIDs was 3 (95% CI, 2-4);4 capsaicin had an NNT of 4 (95% CI, 3-5) after 4 weeks of therapy.4 The recommendations also note that glucosamine and/or chondroitin sulfate may alleviate some symptoms of osteoarthritis of the knee, but should be discontinued if no benefit is observed after 6 months.

When something stronger is needed. For moderate to severe pain that has not responded to oral agents, intraarticular (IA) injections with corticosteroids are recommended, as are IA hyaluronate injections (SOR: 78% and 64%, respectively). Weak opioids/low-dose narcotics round out the recommendations for treating moderate pain, with stronger opioids reserved for patients whose pain is severe.

When to consider surgery

Joint replacement surgery is recommended for patients who do not achieve adequate pain relief and functional improvement from nonpharmacologic and pharmacologic modalities (SOR: 96%). A meta-analysis of 74 studies assessing quality of life 1 to 7 years after total hip and total knee replacement (THR and TKR) found substantial improvement in pain and function, but variable effects on mental health and social functioning. Risk factors for poor outcomes include older age; more (or more severe) preoperative pain; medical comorbidities; musculoskeletal comorbidities such as low back pain, with functional limitations; low mental health scores; and OA in the hip that was not replaced.10,11

Unicompartmental knee replacement (UKR) had an SOR of 76%. Reviews that compared TKR to UKR found similar 5-year outcomes in knee pain and function. Those who underwent UKR had better range of motion, but prosthesis survival at 10 years was better in those with TKR (>90% vs 85% to 90%).12

In young adults, osteotomy and jointpreserving procedures are recommended for hip OA, especially when dysplasia is present. In young, active patients with unicompartment OA, high tibial osteotomies may delay TKR by as long as 10 years.13

Joint lavage and arthroscopic debridement in knee OA remain controversial, although they may provide short-term symptom relief (SOR: 60%). Joint fusion as a salvage procedure after failed TKR had an SOR of 69%.

Work as a team to improve outcomes

The inevitable increase in the number of patients with OA of the hips and knees underscores the importance of having a range of treatment strategies, often best delivered by a multidisciplinary team with the family physician at the helm. The OARSI guidelines, which are backed by both a thorough review of research findings and expert consensus, can help you convince patients to take an active role in managing this potentially debilitating condition. Patients’ commitment to lifestyle modifications and self-management, bolstered by your guidance and support, is the most effective way to keep patients with OA on the move.

Correspondence
Greg P. Gutierrez, MD, Associate Professor, University of Colorado Denver Health Sciences Center, Department of Family Medicine, Denver Health and Hospital, 660 Bannock St., Denver, CO 80218; [email protected].

Practice recommendation

  • Teach patients that self-care is key to successful management of osteoarthritis (Osteoarthritis Research Society International [OARSI] Evidence 1a
  • Encourage patients to regularly engage in aerobic, muscle-strengthening, and range-of-motion exercise (Ia: knee; IV: hip).
  • Recommend that patients try acetaminophen (≤4 g/d) before considering other analgesics for mild to moderate joint pain (Ia: knee; IV: hip).
  • Prescribe the lowest effective dose of nonsteroidal anti-inflammatory drugs (NSAIDs) and avoid using them for long-term therapy (Ia).

OARSI level of evidence:

Ia: Meta-analysis of randomized controlled trials (RCTs)
Ib: RCT
IIa: Controlled study without randomization
IIb: Quasi-experimental study
III: Nonexperimental, descriptive studies
IV: Expert committee reports/opinion/experience

Osteoarthritis (OA) and other rheumatic conditions account for as many office visits as cardiovascular disease or essential hypertension, according to national data, and most involve primary care physicians.1 As the population ages, the prevalence of OA—estimated at 46.4 million in 2005 in the United States alone—will continue to rise.2,3 So, too, will the number of patients needing treatment for pain and functional limitations related to OA of the hips and knees.

Physicians who treat these patients have a new tool at their disposal: the Osteoarthritis Research Society International (OARSI)’s evidence-based, expert consensus guidelines for the management of hip and knee OA. These recommendations, published in February 2008, are the first “internationally agreed and universally applicable guidelines for the management of these global disorders.”4

In caring for patients with OA of the hips or knees, family physicians should keep in mind 2 guiding principles at the heart of the OARSI recommendations:

  • the importance of lifestyle modification, including regular exercise, in coping with this degenerative, potentially debilitating disease; and
  • the need to incorporate both nonpharmacologic interventions and drug therapy to achieve optimal care.4

International team sifts through the evidence

To develop the guidelines, OARSI convened a committee of 16 physicians from 6 countries and 2 continents, with expertise in 4 disciplines: rheumatology, orthopedics, evidence-based medicine, and primary care. The team reviewed national and regional guidelines and studied systematic reviews; meta-analyses; randomized controlled trials (RCTs); controlled and uncontrolled trials; cohort, case-control, and cross-sectional studies; and economic evaluations from 1945 through 2001. The team also conducted a systematic review of evidence from January 2002 through January 2006.4,5 To ensure the quality of evidence hierarchy, the team used internationally accepted research tools.

AP and tunnel images are key to OA diagnosis

A diagnosis of knee or hip osteoarthritis (OA) requires a medical history; physical examination; radiologic assessment, with standing X-rays of the lower extremities, including anterior-posterior and tunnel views for knee OA; and the exclusion of other conditions.30 The tunnel view shown here reveals bone-on-bone articulation in the medial compartment of the left knee, and demonstrates the importance of standing X-rays.

Differential diagnosis includes gout, pseudogout, rheumatoid arthritis, patella-femoral pain, pes anserine (knee) bursitis, iliotibial band pathology, meniscal tear, cruciate tears, and tumors. No blood tests are indicated unless an inflammatory process is suspected. Synovial fluid in an osteoarthritic knee has a white cell count of <2000/uL.31

The team used several criteria to rate the recommended strategies, including level of evidence, effect size for pain relief, level of consensus, and strength of recommendation (SOR). All of these criteria are included (and defined) in an at-a-glance summary of the OARSI recommendations ( TABLE ).

In particular, the SOR, which is used throughout this article, is an overall rating that reflects the opinions of the team members after consideration of the research evidence for efficacy, safety, and cost-effectiveness. It is based on a visual analog scale of 0 to 100 mm and is expressed as a percentage.

TABLE
OARSI guidelines rate the evidence for osteoarthritis treatment options

RECOMMENDATION SOR, % (95% CI)*/ LEVEL OF CONSENSUS, % LEVEL OF EVIDENCE ES (95% CI)§
Nonpharmacologic
Education, self-help, patient-driven treatment97 (95 to 99)/NAIa: educationNA
Aerobic, muscle-strengthening, and range-of-motion exercises96 (93 to 99)/85Ia: knee
IV: hip
Ib: hip, water-based
0.52 (0.34 to 0.70): aerobic
0.32 (0.23 to 0.42): strength
0.25 (0.02 to 0.47): water-based
Weight loss96 (92 to 100)/100Ia0.13 (-0.12 to 0.38)
Walking aids90 (84 to 96)/100IVNA
Physical therapy89 (82 to 96)/100IVNA
Appropriate footwear/insoles77 (66 to 88)/92IV: footwear
Ia: insoles
NA
Knee braces76 (69 to 83)/92IaNA
Telephone contact66 (57 to 75)/77Ia: knee; IV: hip0.12 (0 to 0.24)
Thermal modalities64 (60 to 68)/77Ia0.69 (-0.07 to 1.45)
Acupuncture59 (47 to 71)/69Ia0.51 (0.23 to 0.79)
TENS58 (45 to 72)/69IaNA
Pharmacologic
Oral NSAIDs93 (88 to 99)/100Ia0.32 (0.24 to 0.39)
Acetaminophen ≤4 g/d92 (88 to 99)/77Ia: knee; IV: hip0.21 (0.02 to 0.41)
Topical NSAIDs/capsaicin85 (75 to 95)/100Ia0.41 (0.22 to 0.59)
Weak opioids/narcotics82 (74 to 90)/92IaNA
IA corticosteroid injections78 (61 to 95)/69Ia: knee; Ib: hip0.72 (0.42 to 1.02)
IA hyaluronate injections64 (43 to 85)/85Ia0.32 (0.17 to 0.47)
Glucosamine and/or chondroitin63 (44 to 82)/92Ia: glucosamine0.45 (0.04 to 0.86)
Surgical treatments
Joint replacement96 (94 to 98)/92IIINA
Unicompartmental knee replacement76 (64 to 88)/100IIIbNA
Osteotomy/joint preservation75 (64 to 86)/100IIbNA
Joint fusion69 (57 to 82)/100IVNA
Joint lavage/arthroscopic debridement60 (47 to 82)/100Ib0.09 (-0.27 to 0.44): lavage
-0.01 (-0.37 to 0.35): debridement
CI, confidence interval; ES, effect size for pain relief; IA, intraarticular; NA, not available; NSAIDs, nonsteroidal anti-inflammatory drugs; OARSI, Osteoarthritis Research Society International; SOR, strength of recommendation; TENS, transcutaneous electrical nerve stimulation
* SOR (strength of recommendation) is an overall rating that reflects the opinions of OARSI team members after consideration of the research evidence for efficacy, safety, and cost-effectiveness. SOR is based on a visual analog scale of 0 to 100 mm and is expressed as a percentage.
Level of consensus is the estimated extent of agreement among committee members, expressed as a percentage.
Level of evidence is broken into 6 categories: Ia: meta-analysis of randomized controlled trials (RCTs); Ib: RCT; IIa: controlled study without randomization; IIb: quasi-experimental study; III: nonexperimental, descriptive studies; and IV: expert committee reports/opinion/experience.
§ES (effect size for pain relief) is a measure of the standard mean difference between interventions (eg, treatment vs placebo): 0.2 (small); 0.5 (moderate); and >0.8 (large). The ES refers to the knee and hip unless otherwise specified.
Adapted from: Zhang et al.4
 

 

OARSI emphasizes patient education

Patient education about self-care and lifestyle modifications, such as weight loss, exercise, and pacing of activities to reduce the load on the affected joints, is OARSI’s strongest nonpharmacologic recommendation (SOR: 97%). The guidelines also call for the following interventions:

  • correcting mechanical abnormalities of the skeleton;
  • helping patients lose weight;
  • assisting patients with smoking cessation efforts;6
  • directing the use of nonprescription medications;
  • prescribing assistive devices; and
  • prescribing appropriate prescription drugs.

Nondrug options: Exercise that achy joint

To many patients, being told to exercise a joint in which movement is associated with stiffness and bone-on-bone pain seems counterintuitive. Referring to the findings of the OARSI panel may be helpful in explaining the importance of regular aerobic, muscle-strengthening, and range-of-motion exercises, all of which are strongly recommended (SOR: 96%). Exercise can be as simple as “regular aerobic walking” and home-based strengthening of the quadriceps.4 For patients with arthritic hips, water-based exercises are recommended.

Obesity can increase the risk of developing OA of the hips and knees, and excess weight puts extra stress on joints that are already arthritic. Thus, weight loss is both a risk modification factor (see “Is your patient at risk of OA? Take steps now” ) and a key OA management strategy (SOR: 96%). In a meta-regression analysis conducted by the committee, a reduction of >5% of body weight or a loss at a rate of >0.24% per week was associated with significant improvement in disability. One RCT had a number needed to treat (NNT) of 3 (95% confidence interval [CI], 2-9) to achieve improved pain and function scores after a 2-month low-energy diet.7

Is your patient at risk of OA? Take steps now

Risk factors for osteoarthritis (OA) include:14-19

  • mechanical abnormalities, such as varus (bowlegged) and valgus (knock-kneed) angulations;
  • flat feet, and heel pronation and supination;
  • a history of joint surgery or acute injuries, particularly to the anterior cruciate ligament (ACL) or meniscus;
  • obesity;
  • manual labor (any job that involves heavy lifting, together with kneeling and squatting);
  • participation in competitive or high-intensity sports; and
  • a family history of OA (based on mounting evidence of a genetic link).20-22

Lack of neuromuscular control (proprioception) of the knee is another risk factor, since it can expose the internal joint to forces that would otherwise be absorbed by muscle. Exposure of the joint to excess forces can occur if the impact is rapid, leaving the muscle without adequate time to contract to absorb the force, or the muscle is fatigued and weak from prolonged exercise.23,24

Work with patients to modify risk. In discussing risk modification with patients, emphasize that high-intensity running, especially when practiced for years, increases the risk of OA of the knees.25 Indeed, high-impact activity of any kind subjects knee cartilage to significant single and repetitive impact loads and torsional loads.17,26 Point out, however, that some physical activity is needed to maintain normal metabolic activity of cartilage in a healthy joint and that recreational, mild-intensity running or jogging does not appear to increase the risk for OA.27

Be aggressive with knee injuries. As noted earlier, a history of acute ACL or meniscus injury is a risk factor for OA. Knee trauma with effusions that develop rapidly (within 2-12 hours) is associated with high risk of significant intraarticular damage to the ACL, meniscus, and articular cartilage.28 A study of pediatric and adolescent patients who underwent magnetic resonance imaging for possible internal knee injury found cartilage injuries to be the most common.29

To avoid additional damage, manage knee trauma with effusions as a significant injury. Treatment includes bracing, physical therapy, low-impact exercise, and possibly even cross-training or job modification. Advise patients to continue physical therapy until strength and proprioception are fully recovered and no pain or effusion remains, which generally takes about 6 to 8 weeks, and not to return to normal activity prematurely.

Don’t underestimate the power of a phone call

Other nonpharmacologic recommendations include referral to a physical therapist for evaluation and exercise instruction (SOR: 89%); instruction in the use of walking aids, such as a cane or crutch in the contralateral hand, to improve biomechanics (SOR: 90%); and the use of braces to support unstable knees, an unproven intervention that may increase proprioception and stability (SOR: 76%). Physicians should also recommend footwear with insoles or lateral wedges to decrease lateral thrust of the knee and medial compartment forces (SOR: 77%).

Regular telephone contact, possibly on a monthly basis, is a suggested strategy for promoting self-care, tested in patients with OA of the knee but recommended for those with arthritic hips solely on the basis of expert opinion. A number of other modalities, including thermal therapy (heat treatments with warm water or wax, or cold therapy with a 20-minute ice massage), transcutaneous electrical nerve stimulation (TENS), and acupuncture, are recommended for symptom relief.

 

 

Drug therapy: Start with acetaminophen

The OARSI guidelines cite acetaminophen as an “effective initial oral analgesic” for mild to moderate pain in patients with OA of the hips or knees (SOR: 92%).4 In analyses conducted by the committee, the NNT to achieve an improvement in pain ranged from 1 to 2 in an earlier systematic review8 to 4 to 16 in a subsequent meta-analysis.9

Prescribe NSAIDs for short-term relief. While acetaminophen is considered the preferred long-term oral treatment, the strongest pharmacologic recommendation for alleviating the pain and stiffness associated with OA of the hip or knee is for nonsteroidal anti-inflammatory drugs (NSAIDs) (SOR: 93%). The caveat, however, is that NSAIDs should be used in the lowest effective dose and are not considered a long-term option. Patients with increased gastrointestinal (GI) risk should use either a cyclooxygenase-2 (COX-2) agent or an NSAID with a proton pump inhibitor or misoprostol for GI protection.

For those with cardiovascular risks, both nonselective NSAIDs and COX-2 agents require caution; here, too, the lowest dose for the shortest possible duration is recommended.

The guidelines also call for the use of topical agents, such as topical NSAIDs and capsaicin, for relief of symptoms (SOR: 85%). The NNT for topical NSAIDs was 3 (95% CI, 2-4);4 capsaicin had an NNT of 4 (95% CI, 3-5) after 4 weeks of therapy.4 The recommendations also note that glucosamine and/or chondroitin sulfate may alleviate some symptoms of osteoarthritis of the knee, but should be discontinued if no benefit is observed after 6 months.

When something stronger is needed. For moderate to severe pain that has not responded to oral agents, intraarticular (IA) injections with corticosteroids are recommended, as are IA hyaluronate injections (SOR: 78% and 64%, respectively). Weak opioids/low-dose narcotics round out the recommendations for treating moderate pain, with stronger opioids reserved for patients whose pain is severe.

When to consider surgery

Joint replacement surgery is recommended for patients who do not achieve adequate pain relief and functional improvement from nonpharmacologic and pharmacologic modalities (SOR: 96%). A meta-analysis of 74 studies assessing quality of life 1 to 7 years after total hip and total knee replacement (THR and TKR) found substantial improvement in pain and function, but variable effects on mental health and social functioning. Risk factors for poor outcomes include older age; more (or more severe) preoperative pain; medical comorbidities; musculoskeletal comorbidities such as low back pain, with functional limitations; low mental health scores; and OA in the hip that was not replaced.10,11

Unicompartmental knee replacement (UKR) had an SOR of 76%. Reviews that compared TKR to UKR found similar 5-year outcomes in knee pain and function. Those who underwent UKR had better range of motion, but prosthesis survival at 10 years was better in those with TKR (>90% vs 85% to 90%).12

In young adults, osteotomy and jointpreserving procedures are recommended for hip OA, especially when dysplasia is present. In young, active patients with unicompartment OA, high tibial osteotomies may delay TKR by as long as 10 years.13

Joint lavage and arthroscopic debridement in knee OA remain controversial, although they may provide short-term symptom relief (SOR: 60%). Joint fusion as a salvage procedure after failed TKR had an SOR of 69%.

Work as a team to improve outcomes

The inevitable increase in the number of patients with OA of the hips and knees underscores the importance of having a range of treatment strategies, often best delivered by a multidisciplinary team with the family physician at the helm. The OARSI guidelines, which are backed by both a thorough review of research findings and expert consensus, can help you convince patients to take an active role in managing this potentially debilitating condition. Patients’ commitment to lifestyle modifications and self-management, bolstered by your guidance and support, is the most effective way to keep patients with OA on the move.

Correspondence
Greg P. Gutierrez, MD, Associate Professor, University of Colorado Denver Health Sciences Center, Department of Family Medicine, Denver Health and Hospital, 660 Bannock St., Denver, CO 80218; [email protected].

References

1. Hootman JM. Magnitude and characteristics of arthritis and other rheumatic conditions on ambulatory medical care visits, United States, 1997. Arthritis Rheum. 2002;47:571-581.

2. Lawrence R, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. 1998;41:778-799.

3. US Department of Health and Human Services. CDC: prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation - United States, 2003–2005. MMWR. 2006;55:1089-1092.

4. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-162.

5. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartilage. 2007;15:981-1000.

6. Amin S, Niu J, Guermazi A, et al. Cigarette smoking and the risk for cartilage loss and knee pain in men with knee osteoarthritis. Ann Rheum Dis. 2007;66:18-22.

7. Christensen R, Astrup A, Bliddal H. Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial. Osteoarthritis Cartilage. 2005;13:20-27.

8. Towheed TE, Hochberg MC, Judd MG, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2003;(2):CD004257.-

9. Towheed TE, Maxwell L, Judd MG, Catton M, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2006;(1):CD004257.-

10. Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am. 2004;86-A:963-974.

11. Lingard EA, Katz JN, Wright EA, Sledge CB. Kinemax Outcomes Group. Predicting the outcome of total knee arthroplasty. J Bone Joint Surg Am. 2004;86-A:2179-2186.

12. Griffin T, Rowden L, Morgan D, Atkinson R, Woodruff P, Madden G. Unicompartmental knee arthroplasty for the treatment of unicompartmental osteoarthritis: a systematic study. ANZ J Surg. 2007;77:214-221.

13. Virolainen P, Arc HT. High tibial osteotomy for the treatment of osteoarthritis of the knee: a review of the literature and a meta-analysis of follow-up studies. Arch Orthop Trauma Surg. 2004;124:258-261.

14. Felson DT. Relation of obesity and of vocational and avocational risk factors to osteoarthritis. J Rheumatol. 2005;32:1133-1135.

15. Gelber AC, Hochberg MC, Mead LA, Wang NY, Wigley FM, Klag MJ. Joint injury in young adults and risk for subsequent knee and hip osteoarthritis. Ann Intern Med. 2000;133:321-328.

16. Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD. The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA. 2001;286:188-195.

17. Lequesne MG, Dang N, Lane NE. Sport practice and osteoarthritis of the limbs. Osteoarthritis Cartilage. 1997;5:75-86.

18. Griffin TM, Guilak F. The role of mechanical loading in the onset and progression of osteoarthritis. Exerc Sport Sci Rev. 2005;33:195-200.

19. Maetzel A, Makela M, Hawker G, Bombardier C. Osteoarthritis of the hip and knee and mechanical occupational exposure: a systematic overview of the evidence. J Rheumatol. 1997;24:1599-1607.

20. Zhai G, Ding C, Stankovich J, Cicuttini F, Jones G. The genetic contribution to longitudinal changes in knee structure and muscle strength: a sibpair study. Arthritis Rheum. 2005;52:2830-2834.

21. Hirsch R, Lethbridge-Cejku M, Hanson R, et al. Familial aggregation of osteoarthritis: data from the Baltimore Longitudinal Study on Aging. Arthritis Rheum. 1998;41:1227-1232.

22. Felson DT, Couropmitree NN, Chaisson CE, et al. Evidence for a Mendelian gene in a segregation analysis of generalized radiographic osteoarthritis: the Framingham Study. Arthritis Rheum. 1998;41:1064-1071.

23. Christina KA, White SC, Gilchrist LA. Effect of localized muscle fatigue on vertical ground reaction forces and ankle joint motion during running. Hum Mov Sci. 2001;20:257-276.

24. Mizrahi J, Verbitsky O, Isakov E. Fatigue-related loading imbalance on the shank in running: a possible factor in stress fractures. Ann Biomed Eng. 2000;28:463-469.

25. McAlindon TE, Wilson PW, Aliabadi P, Weissman B, Felson DT. Level of physical activity and the risk of radiographic and symptomatic knee osteoarthritis in the elderly: the Framingham study. Am J Med. 1999;106:151-157.

26. Buckwalter JA. Sports, joint injury, and posttraumatic osteoarthritis. J Orthop Sports Phys Ther. 2003;33:578-588.

27. Conaghan PG. Update on osteoarthritis part 1: current concepts and the relation to exercise. British J Sports Med. 2002;36:330-333.

28. Maffulli N, Binfield PM, King JB, Good CJ. Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases. J Bone Joint Surg Br. 1993;75:945-949.

29. Oeppen RS, Connolly SA, Bencardino JT, Jaramillo D. Acute injury of the articular cartilage and subchondral bone: a common but unrecognized lesion in the immature knee. Am J Roentgenol. 2004;182:111-117.

30. Felson DT. Osteoarthritis of the knee. N Engl J Med. 2006;354:841-848.

31. Hassebacher B. Arthrocentesis, synovial fluid analysis and synovial biopsy. In: Schumacher HR, Klippel JH, Koopman WJ, eds. Primer on the Rheumatic Diseases. Atlanta, GA: Arthritis Foundation; 1993:67-72.

References

1. Hootman JM. Magnitude and characteristics of arthritis and other rheumatic conditions on ambulatory medical care visits, United States, 1997. Arthritis Rheum. 2002;47:571-581.

2. Lawrence R, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. 1998;41:778-799.

3. US Department of Health and Human Services. CDC: prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation - United States, 2003–2005. MMWR. 2006;55:1089-1092.

4. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-162.

5. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartilage. 2007;15:981-1000.

6. Amin S, Niu J, Guermazi A, et al. Cigarette smoking and the risk for cartilage loss and knee pain in men with knee osteoarthritis. Ann Rheum Dis. 2007;66:18-22.

7. Christensen R, Astrup A, Bliddal H. Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial. Osteoarthritis Cartilage. 2005;13:20-27.

8. Towheed TE, Hochberg MC, Judd MG, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2003;(2):CD004257.-

9. Towheed TE, Maxwell L, Judd MG, Catton M, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2006;(1):CD004257.-

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Issue
The Journal of Family Practice - 57(10)
Issue
The Journal of Family Practice - 57(10)
Page Number
644-649
Page Number
644-649
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Managing osteoarthritis: What’s best for your patient?
Display Headline
Managing osteoarthritis: What’s best for your patient?
Legacy Keywords
Greg P. Gutierrez; osteoarthritis; analgesics; lifestyle modification
Legacy Keywords
Greg P. Gutierrez; osteoarthritis; analgesics; lifestyle modification
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