Evaluation and Treatment of the Patient with Osteoarthritis

,

Applied Evidence

Evaluation and Treatment of the Patient with Osteoarthritis

J Fam Pract. 2001 September;50(9):791-797

By

Brian T. Easton, MD

References

1. Centers for Disease Control and Prevention. Prevalence of disabilities and associated health conditions—United States, 1991-1992. JAMA 1994;272:735-36.

2. Solomon L. Clinical features of osteoarthritis. In: Kelly WN, Harris ED Jr, Ruddy S, Sledge CB, eds. Textbook of rheumatology. 5th ed. Vol 2. Philadelphia, Pa: WB Saunders; 1997;1383-93.

3. Bellamy N, Buchanan WW, Goldsmith CH, Cambell J, Stitt LW. 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. J Rheumatol 1988;15:1833-40.

4. Badley EM, Rasooly I, Webster GK. Relative importance of musculoskeletal disorders as a cause of chronic health problems, disability and health care utilization: findings from the 1990 Ontario Health Survey. J Rheumatol 1994;21:505-14.

5. Ruddy S. Kelley’s textbook of rheumatology. 6th ed. St. Louis, Mo: W.B Saunders Company; 2001.

6. Stange KC, Zyzanski JS, Jaen CR, et al. Illuminating the ‘black box’: a description of 4454 patient visits to 138 family physicians. J Fam Pract 1998;46:377-89.

7. Hochberg MC. Epidemiology and genetics of osteoarthritis. Curr Opin Rheumatol 1991;3:662-68.

8. Lanyon P, Muir K, Doherty S, Doherty M. Assessment of a genetic contribution to osteoarthritis of the hip: sibling study. BMJ 2000;321:1179-83.

9. Lawrence RD, Everett D, Hochberg MC. Arthritis. In: Huntley R, Cornoni-Huntley J, eds. Health status and well-being of the elderly: national health and nutrition examination-I epidemiologic follow-up survey. Oxford, England: Oxford University Press; 1990.

10. Altman RD. Criteria for classification of clinical osteoarthritis. J Rheumatol 1991;18(suppl):10-12.

11. Altman R, Asch E, Bloch D, et al. Development criteria for the classification and reporting of osteoarthtitis: classification of osteoarthritis of the knee. Arthritis Rheum 1986;29:1039-49.

12. Altman R, Alarcon G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991;34:505-14.

13. Altman R, Alarcon G, Appelrouth D, et al. The American College of Rheumatology criteria for classification and reporting of osteoarthritis of the hand. Arthritis Rheum 1990;33:1601-10.

14. Van Baar ME, Assendelft WJJ, Dekker J, Oostendorp RAB, Bijlsma JW. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials. Arthritis Rheum 1999;42:1361-69.

15. Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized controlled trial. Ann Intern Med 2000;132:173-81.

16. Osiri M, Welch V, Brosseau L, Shea B, McGowan J, Tugwell P, Wells G. Transcutaneous electrical nerve stimulation for knee osteoarthritis. The Cochrane library Oxford, England: Update Software; 2001.

17. Verhagen AP, de Vet HCW, de Bie RA, Kessels AGH, Boers M, Knipschild PG. Balneotherapy for rheumatoid arthritis and osteoarthritis. The Cochrane library Oxford, England: Update Software; 2001.

18. Brosseau L, Welch V, Wells G, et al. Low level laser therapy (classes I, II and III) for treating osteoarthritis. The Cochrane library Oxford, England: Update Software; 2001.

19. Puett DW, Griffin MR. Published trials of nonmedicinal and noninvasive therapies for hip and knee osteoarthritis. Ann Intern Med 1994;121:133-40.

20. Lorig K, Lubeck D, Kraines RG, et al. Outcomes of self-help education for patients with arthritis. Arthritis Rheum 1985;28:680-85.

21. Lorig K, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis and Rheumat 1993;36:439-46.

22. Weinberger M, Tierney WM, Booher P, et al. Can the provision of information to patients with osteoarthritis improve functional status? A RCT. Arthritis Rheum 1989;32:1577-83.

23. Weinberger M, Tierney WM, Cowper PA, et al. Cost-effectiveness of increased telephone contact for patients with osteoarthritis: A RCT. Arthritis Rheum 1993;36:243-46.

24. Superio-Cabuslay E, Ward MM, Lorig KR. Patient education interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with nonsteroidal anti-inflammatory drug treatment. Arthritis Care Res 1996;9:292-301.

25. Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SL. Comparison of an inflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee. N Eng J Med 1991;325:87-91.

26. Williams JH, Ward JR, Egger JM, Neuner R, et al. Comparison of naproxen and acetaminophen in a two-year study of treatment of osteoarthritis of the knee. Arthritis Rheum 1993;36:1196-206.

27. American College of Rheumatology. Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis Rheum 2000;43:1905-15.

28. Roth SH, Fleischmann RM, Burch FX, et al. Around-the-clock, controlled-release oxycodone therapy for osteoarthritis-related pain: placebo-controlled trial and long-term evaluation. Arch Intern Med 2000;160:853-60.

29. Watson MC, Brookes ST, Kirwan JR, Faulkner A. Non-aspirin, non-steroidal anti-inflammatory drugs for treating osteoarthritis of the knee. The Cochrane library Oxford, England: Update Software; 2001.

30. Towheed T, Shea B, Wells G, Hochberg M. Analgesia and non-aspirin, non-steroidal anti-inflammatory drugs for osteoarthritis of the hip. The Cochrane library Oxford, England: Update Software; 2001.

31. Eccles Freemantel N, Mason J. North of England evidence based guideline development project: summary guideline for non-steroidal anti-inflammatory drugs versus basic analgesia in treating the pain of degenerative arthritis. BMJ 1998;317:526-30.

32. Bensen WG, Fiechtner JJ, McMillen JI, et al. Treatment of osteoarthritis with celecoxib, a cyclooxygenase-2 inhibitor: a randomized controlled trial. Mayo Clin Proc 1999;74:1095-105.

33. Yocum D, Fleischmann R, Dalgin P, et al. Safety and efficacy of meloxicam in the treatment of osteoarthritis: a 12-week, double-blind, multiple-dose, placebo-controlled trial. Arch Intern Med 2000;160:2947-54.

34. Cannon GW, Caldwell JR, Holt P, et al. Rofecoxib, a specific inhibitor of cyclooxygenase 2, with clinical efficacy comparable with that of diclofenac sodium: results of a one-year, randomized clinical trial in patients with osteoarthritis of the knee and hip. Arthritis Rheum 2000;43:978-87.

35. Saag K, van der Heijde D, Fisher C, et al. Rofecoxib, a new cyclooxygenase 2 inhibitor shows sustained efficacy comparable with other nonsteroidal anti-inflammatory drugs. Arch Intern Med 2000;9:1124-34.

36. Silverstein RE, Faich G, Goldstein JL. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis-the CLASS study: a randomized controlled trial. JAMA 2000;284:1247-55.

37. Schoenfeld P. Gastroitestinal safety profile of meloxicam: a meta-analysis and systematic review of randomized controlled trials. Am J Med 1999;107:48S-54S.

38. Langman MJ, Jensen DM, Watson DJ, et al. Adverse upper gastrointestinal effects of rofecoxib compared with NSAIDs. JAMA 1999;282:1929-33.

39. Watson DJ, Harper SE, Zhao PL, et al. Gastrointestinal tolerability of the selective cyclooxygenase-2 (COX-2) inhibitor rofecoxib compared with nonselective cox-1 and cox-2 inhibitors in osteoarthritis. Arch Intern Med 2000;160:2998-3003.

40. McAlindon TE, LaValley MP, Gulin JP, Felson DT. Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA 2000;283:1469-75.

41. Towheed TE, Anastassiades TP, Shea B, Houpt J, Welch V, Hochberg MC. Glucosamine therapy for treating osteoarthritis. The Cochrane library Oxford, England: Update Software; 2001.

42. Little CV, Parsons T. Herbal Therapy for treating osteoarthritis. The Cochrane library, Oxford, England: Updated Software; 2001.

43. Ezzo J, Hadhazy V, Birch S, et al. Acupuncture for osteoarthritis of the knee: a systematic review. Arthritis Rheum 2001;44:819-25.

44. Gordon A, Merenstein JH, D’Amico F, et al. The effects of therapeutic touch on patients with osteoarthritis of the knee. J Fam Pract 1998;47:271-77.

45. Hochberg MC, Altman RD, Brandt KD, Clark BM, et al. Guidelines for the medical management of osteoarthritis: part II, osteoarthritis of the knee. Arthritis Rheum 1995;38:1541-46.

46. Towheed TE, Hochberg MC. A systematic review of randomized controlled trials of pharmacological therapy in osteoarthritis of the knee with an emphasis on trial methodology. Sem Arthritis Rheum 1997;26:755-70.

47. Altman RD, Moskowitz R. Intraarticular sodium hyaluronate (Hyalgan) in the treatment of patients with osteoarthritis of the knee: a randomized clinical trial. Hyalgan Study Group. J Rheumatol 1998;25:2203-12.

48. Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Alt Therapies 2000;6:68-80.

49. Towheed TE, Hochberg MC. Health-related quality of life after total hip replacement. Sem Arthritis Rheum 1996;26:483-91.

50. Chang RW, Pellissier JM, Hazen GB. A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA 1996;275:858-65.

51. National Institutes of Health. National Intitutes of Health consensus statement: total hip replacement. Nat Instit Health 1994;12:1-31.

52. Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis: part I osteoarthritis of the hip. Arthritis Rheum 1995;38:1535-40.

53. Felson DT. Osteoarthritis. Rheum Dis Clin N Am 1990;16:499-512.

54. Hernborg JS, Nilsson BE. The natural course of untreated osteoarthritis of the knee. Clin Orthop 1977;123:130-37.

55. Danielsson L, Hernborg J. Clinical and roentgenologic study of knee joints with osteophytes. Clin Orthop 1970;69:302-12.

56. Danielsson L. Incidence and prognosis of coxarthrosis. Acta Orthop Scand 1964;66(suppl):9-87.

Osteoarthritis (OA) is a chronic and progressive disease in which damage is done to the joint and surrounding tissue. In the United States, OA is found in 6% of people older than 30 years and in 50% of those older than 60 years.^1,2 It is the most common cause of disability in the United States and leads to considerable costs due to medical and surgical interventions and frequent absences from work.^3-5 OA accounts for 2% of all visits to family physicians and is the 10th leading diagnosis encountered.⁶ Thus, a family physician can expect to have 2 or 3 patient encounters per week in which OA is one of the diagnoses. With the growing elderly population, this burden is likely to increase.

Pathophysiology

In OA, the smooth surface of hyaline cartilage develops irregularities because of alterations at the cellular level and gross mechanical forces.² The role of inflammation has been debated in recent years, and its exact role is unknown. As OA progresses, the nearby bone remodels and forms further joint irregularities and osteophytes. These changes lead to narrowing of the joint space, and in some cases, chronic synovitis. Clinically, this causes pain, restricted movement, and periarticular muscle wasting. Treatment is aimed at these symptoms and structural abnormalities. The joints most commonly affected include the knees, hips, cervical and lumbosacral spine, distal interphalangeal (DIP) joints (producing Heberden nodes), proximal interphalangeal (PIP) joints (producing Bouchard nodes), and the first carpometacarpal joints of the hand. It is not known why these changes occur in some people and not in others. Epidemiologic studies and a recent sibling study raise the question of genetic influences in OA of the hip.^7,8

Diagnosis

The diagnosis of OA is made on the basis of clinical and radiographic features. Few studies have compared a diagnostic test or strategy with a gold standard. Unfortunately, we do not have any good data about the usefulness of individual history and physical examination elements for diagnosing OA. Radiographs suggesting the diagnosis of OA (joint space narrowing, presence of osteophytes, irregular joint surfaces, sclerosis of subchondral bone, or bony cysts) must be closely correlated with clinical symptoms. According to epidemiologic surveys, only one half of patients with radiographic changes of OA of the knee complain of persistent pain.⁹ Classification criteria for OA of the knee, hip, and hands have been developed; they are outlined in Tables 1 Table 2 through Table 3.^10,13

Although these criteria have limitations, they are becoming the standard for defining these types of OA and have been adapted by the American College of Rheumatology.^11-13 Currently, there are no criteria for diagnosing OA of the back. When evaluating a patient with joint pain, other diagnoses must be considered (ie, rheumatoid arthritis, gout, pseudogout, septic arthritis, bursitis, and tendonitis).

Treatment

Most of the treatments of OA address the symptoms rather than the cause of the disease. The short-term goal is to decrease pain; long-term goals are to improve functioning and slow progression of disease. Table 4 provides a summary of treatment options.

Exercise

A systematic review of 12 randomized controlled trials (RCTs) showed beneficial effects of exercise therapy in patients with mild to moderate OA of the knee and, to a lesser extent, the hip.¹⁴ Benefits included improvements in pain, self-reported disability, walking performance, and the patient’s global assessment of symptoms. Insufficient evidence was available to recommend one type of exercise program over another. Exercise interventions included aerobic exercises, strength training, range of motion exercises, and fitness walking. Exercise programs were conducted as individuals or groups, supervised or home-based. Although this review was limited by the small number of good studies, recommending exercise for OA may improve patients’ symptoms and add other health benefits.

Physical Therapy

A recent RCT compared 4 weeks of manual physical therapy plus a supervised knee exercise program with sham ultrasound for treatment of OA of the knee.¹⁵ By 8 weeks, 6-minute walk distances had improved by 13% in the treatment group compared with no change in the placebo group; osteoarthritis index scores had improved 56% over baseline compared with 15% in the placebo group. One year following therapy 5% of the treated group had undergone knee arthroplasty compared with 20% of the untreated group (number needed to treat = 7). Given these clinically important improvements, physical therapy should be an early choice in the treatment of OA.

A systematic review of transcutaneous electrical nerve stimulation (TENS) for treatment of OA of the knee found that this noninvasive modality offered significant pain relief.¹⁶ Both high-frequency and strong burst mode TENS showed significant improvement in pain relief when used for 4 weeks or more. Also, the acupuncture-like TENS improved pain relief, stiffness, and walking time in a 2-week placebo-controlled trial.