Osteoarthritis: Managing without surgery

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Applied Evidence

Osteoarthritis: Managing without surgery

J Fam Pract. 2009 July;58(7):354-361

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References

1. Ebell M, Siwek J. AFP: Doing more to help you get the best evidence. Am Fam Physician. 2004;69:483-484.

2. Mason L, Moore RA, Derry S, et al. Systematic review of topical capsaicin for the treatment of chronic pain. BMJ. 2004;228:991.-

3. Fox BA, Schmitz E, Wallace R. Glucosamine and chondroitin for osteoarthritis, Family Practice Inquires Network Clinical Inquires. Am Fam Physician. 2006;73:1245-1247.

4. Towheed TE, Maxwell L, Anastassiades TP, et al. Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev. 2005;(2):CD002946.-

5. Herrero-Beaumont G, Ivorra JA, Del Carmen TM, et al. Glucosamine sulfate in the treatment of knee osteoarthritis symptoms. Arthritis Rheum. 2007;56:555-567.

6. Clegg DO, Reda D, Harris CL, et al. Glucosamine, chrondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354:795-808.

7. Rozendaal RM, Koes BW, von Osch GJ, et al. Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial. Ann Intern Med. 2008;148:268-277.

8. Manheimer E, Linde K, Lao L, et al. Meta-analysis: acupuncture for OA of the knee. Ann Intern Med. 2007;146:868-877.

9. Hinman RS, Crossley KM, McConnell J, et al. Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial. BMJ. 2003;327:135.-

10. Bjordal JM, Johnson MI, Lopes-Martins RA, et al. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord. 2007;8:51.-

11. Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2003;48:370-377.

12. Arroll B, Goodinyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ. 2004;328:869-873.

13. Palacios L, Jones W, Mayo H. Do steroid injections help with osteoarthritis of the knee? J Fam Pract. 2004;53:921-922.

14. Bellamy N, Campell J, Robinson V, et al. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;(2):CD005321.-

15. Arrich J, Piribauer F, Mad P, et al. Intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee: systematic review and meta-analysis. CMAJ. 2005;172:1039-1043.

16. Medina JM, Thomas A, Denegar CR. Knee osteoarthritis: should your patient opt for hyaluronic acid injection? J Fam Pract. 2006;55:669-675.

17. Modawal A, Fley J, Shukla R, et al. Hyaluronic acid injections relieve knee pain. J Fam Pract. 2005;54:758-767.

18. Waddell DD. Viscosupplementation with hyaluronans for osteoarthritis of the knee: clinical efficacy and economic implications. Drugs Aging. 2007;24:629-642.

19. Kichner M, Marshall D. A double-blind randomized controlled trial comparing alternate forms of high molecular weight hyaluronan for treatment of osteoarthritis of the knee. Osteoarthritis Cartilage. 2006;14:154-162.

20. Richette P, Ravaud P, Conrozier T, et al. Effect of hyaluronic acid in symptomatic hip osteoarthritis: a multicenter, randomized, placebo-controlled trial. Arthritis Rheum. 2009;60:824-830.

21. Underwood M. Advice to use topical or oral ibuprofen for chronic knee pain in older people: randomized controlled trial and patient preference study. BMJ. 2008;336:138-142.

22. Diclofenac gel for osteoarthritis. Medical Letter. 2008;50:31-32.

23. Lin J, Zhang W, Jones A, et al. Efficacy of topical non-steroidal anti-inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomized controlled trials. BMJ. 2004;329:324-329.

24. A diclofenac patch for pain. Medical Letter. 2008;50:1-2.

25. American Geriatrics Society. American Geriatrics Society announces new guidelines to improve pain management, quality of life, and quality of care for older patients. May 1, 2009. Available at: http://www.americangeriatrics.org/news/pain043009.shtml. Accessed June 1, 2009.

26. Peloso PM. Opioid therapy for osteoarthritis of the hip and knee: use it or lose it? J Rheum. 2001;28:6-10.

27. Bannwarth B. Letter: Opioids for osteoarthritis of the hip and knee: which opioids for which patients? J Rheum. 2001;28:1930-1931.

28. Vorsanger G, Xiang J, Jordan D, et al. Post hoc analysis of a randomized, double blind, placebo-controlled efficacy and tolerability study of tramadol extended release for the treatment of osteoarthritis pain in geriatric patients. Clin Ther. 2007;29:2520-2535.

29. Dillie KS, Fleming MF, Mundt MP, et al. Quality of life associated with daily opioid therapy in a primary care chronic pain sample. J Am Board Fam Med. 2008;21:108-117.

30. Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev. 2003;(3):CD004376.-

31. Bartels EM, Lund H, Hagen KB, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2007;(4):CD005523.-

32. Rosemann T, Joos S, Laux G, et al. Case management of arthritis patients in primary care: a cluster-randomized controlled trial. Arthritis Rheum. 2007;57:1390-1397.

33. Vitiello M. CBT for insomnia may reduce osteoarthritis pain. Poster presented at: 60th Annual Meeting of the Gerontological Society of America; November 16-20, 2007; San Francisco, Calif.

34. Erens G, Thronhill T. Complications of total hip arthroplasty. In: Basow DS, ed. UpToDate. Waltham, Mass: UpToDate; 2009. Available at: http://www.uptodate.com. Accessed May 20, 2009.

35. Martin G, Thornhill T. Complications of total knee arthroplasty. In: Basow DS, ed. UpToDate. Waltham, Mass: UpToDate; 2009. Available at: http://www.uptodate.com. Accessed May 20, 2009.

36. Ibrahim SA, Stone RA, Han X, et al. Racial/ethnic differences in surgical outcomes in veterans following knee and hip arthroplasty. Arthritis Rheum. 2005;52:3143-3151.

Price: Medium to high, approaching $1000 for a series of weekly sessions over 3 to 4 months.

Simplicity: Medium. Frequent office visits are standard. Long-term compliance is likely to be low, given the small benefit and the inconvenience.

Tip: Advise patients that acupuncture has not been found to provide any substantial relief, but they should feel free to try it if they’re interested in and can afford this treatment.

Knee braces

Recommended (SOR: C).

Safety: High.

Tolerability: Medium to high. Tolerance depends on the type of brace and its complexity.

FAST TRACK

Basic knee support, such as an elastic patellar-stabilization sleeve, may be beneficial.

Efficacy: Low to medium. Few studies of knee bracing have been done; however, 1 trial showed that 73% of those who used sophisticated taping for 3 weeks reported improvement, vs 10% of no-tape controls.⁹ Pain decreased by 2 points on a 0- to 10-point scale at 3 weeks, and the benefit persisted for an additional 3 weeks after the taping was discontinued. The taping used in the study is impractical for usual and long-term use, but 45% of those who used a sham taping/wrap reported improvement and about a 1-point decrease in pain at 3 and 6 weeks. This suggests that a less sophisticated wrap, such as an elastic patellar-stabilization sleeve, is likely to provide some benefit.

Price: Low (generally less than $30).

Simplicity: High (for a basic sleeve or wrap).

Tips: Recommend an elastic sleeve or wrap with a self-adhesive strap and a patellar opening as a simple first step for OA of the knee. For patients with greater instability, consider recommending a more elaborate brace.

TENS

Recommended (SOR: B).

Safety/Tolerability: High. Withdrawals due to adverse effects of transcutaneous electrical nerve stimulation (TENS) range from 0% to 14%.¹⁰

Efficacy: Medium. The mean improvement with TENS is about 20 points more (on a 100-point scale) than the effect associated with placebo; the data are based on knee OA pain that is moderate to severe. The effect may last 2 to 4 weeks; however, there have been few long-term studies of the benefits of TENS.

Price: Low to medium, depending on availability and insurance coverage.

Simplicity: Medium; TENS units can be used at home, but some patients may be uncomfortable using the apparatus.

Tip: Consider a TENS trial for patients with knee or hip pain that is moderate to severe.

Injections/prescription drugs

Corticosteroid injections

Recommended (SOR: A).

Safety: High for short-term use, but data on the degree and frequency of acute post-injection pain is limited. The possibility of harm from repeated injections is similarly uncertain, although 1 study of patients receiving 8 injections over a 2-year period found no progression in ill effects compared with patients receiving placebo.¹¹

Tolerability: Medium to high. Discomfort from the needle is usually mild.

Efficacy: Low to medium. Critical analysis supports a modest benefit, with an NNT of 2 to 3 for short-term improvement (lasting 3-4 weeks).^12,13 In 1 study, steroid injections produced an average of a 16-point reduction in pain on a 100-point scale. After 1 month, the benefit from the injection is usually not clinically significant.

Price: Low ($100-$200 per injection).

Simplicity: High. The injection itself is a relatively simple procedure, but patient compliance with a scheduled course of repeat injections is uncertain.

Tips: Consider steroid injections for any OA patient with a tense effusion. Because aspiration is often performed just prior to giving the injection, such patients are the best candidates for this procedure. In fact, whenever you aspirate painful effusions, consider injecting a steroid before the needle is removed.

Hyaluronic acid (HA) injections

Recommended with caveats (SOR: A).

Safety: High.

Tolerability: Medium. A small number of patients experience a transitory local flare-up. In addition, some patients have an aversion to injections.

Efficacy: Low. Several recent meta-analyses and systematic reviews of HA injections for knee OA have found a small, often negligible, clinical effect, with placebo usually accounting for up to half of the reported benefit.^14-18 In 1 study with no control group, however, patients experienced about a 60% decrease in composite pain score—and 75% were satisfied or very satisfied with the treatment.¹⁹ Studies of HA injection for hip OA are very limited, but a recent single-injection trial showed no benefit over placebo.²⁰

Any benefit from an HA injection generally lasts 3 to 4 months.

Price: Medium-high. A course of 3 injections costs $700 to $1000 per joint. There are claims of substantial savings due to delayed joint replacement, but these are speculative.