What else can you do? Encourage activity—again
A clear conclusion from many studies is that nonaquatic exercise involving the affected joints, either specifically or as part of a general exercise routine, is clinically beneficial in decreasing pain and increasing function.30 When it comes to aquatic exercises for OA, the data are very limited, but suggest a small short-term benefit.31 Overall, the optimal type and duration of exercise for OA patients, as well as the best location (home or at a gym), is not known.
If your patient has stopped or markedly cut down on the time spent exercising, explore the feasibility of another attempt, and discuss ways to improve compliance. Stress the “bonus” benefits of exercise, such as mood elevation and an overall sense of well-being. If the patient is not undergoing physical therapy, consider a referral.
Use a chronic pain approach
Patients whose OA symptoms continue to be troublesome may benefit from a chronic pain syndrome approach. Nurse case management, phone contact, and extra attention from you may be helpful, along with educational material that the patient can consult between visits (PATIENT HANDOUT).32
Treat insomnia. Studies are insufficient for hypnotics for OA symptoms, but good sleep is a goal of standard pain management. Cognitive-behavioral therapy has been found to be helpful in alleviating sleep problems in patients with OA.33 At a minimum, take a good sleep history and provide basic sleep hygiene education.
Treat vitamin deficiency and depression. Many elderly patients are deficient in vitamin D, and evidence indicates that supplementation supports muscle strengthening and may aid in pain reduction. The effects are mostly preventive, however, and therefore not easily appreciated, so stress the importance of long-term health.
Depression, too, is common among the elderly, particularly for chronic pain patients. If you prescribe antidepressants or vitamin supplementation, emphasize that they are “for your arthritis.”
Inspect footwear. Despite several studies regarding the effects of shoes with inserts on knee OA, it is unclear whether they provide clinical benefit. OARSI supports insoles for selected patients, but acknowledges that evidence is weak. Advise patients to select shoes that are flexible yet supportive and that moderately priced shoes appear to be as good as more expensive footwear for most OA patients. A podiatry consult may be beneficial for patients who have deformities of the feet or complain of foot pain.
Consider assistive devices. Patients with OA who are unstable may benefit from the use of a cane, walker, or other assistive device. Use common sense and individualize treatment, in consultation with an occupational therapist, if necessary.
PATIENT HANDOUT
Living with arthritis: Do’s and Don’ts
Living with arthritis: Do’s and Don’ts
Osteoarthritis is an inflammation of the joint that affects many people as they age, mainly in the knees, hips, and hands. After many years of use, the cartilage that lines the inside of the joint thins and eventually wears off, leaving bone rubbing on bone. At the edge of the joint, the bone may grow into small “spurs” and fluid may increase inside, causing inflammation and pain.
There is no cure for arthritis. But there are many things that you and your doctor can do to make arthritis easier to live with, and to slow its progression. These Do’s and Don’ts may help:
Do get moving. Exercising your arthritic joints, except during acute flare-ups, will strengthen the muscles and help you stay active. Eventually you’ll find that you’re in less pain and can move about more easily.
Do consult a physical therapist to find out what type of exercise is best for you. Ask your doctor for a referral.
Don’t do those exercises during painful flare-ups. This is the time to give your joints a rest.
Do take acetaminophen (Tylenol), as needed, especially during flare-ups. You can take up to 4000 mg a day, but be sure to tell your doctor if you’re taking acetaminophen regularly.
Don’t take acetaminophen without first consulting your doctor if you have liver or kidney disease—or you’re taking a prescription pain medication.
Do ask your doctor about nonsteroidal anti-inflammatory drugs, sometimes called NSAIDs (pronounced N-SEDs). Some people benefit from ibuprofen (Advil, Motrin) or naproxen (Aleve), which are sold over-the-counter. Others take prescription NSAIDs such as Celebrex.
Don’t take NSAIDs without consulting your doctor if you’re over the age of 65. Both prescription and nonprescription NSAIDs can have serious side effects, and should be used with caution, if at all, by older people.
Do consider a trial of glucosamine (1500 mg daily), with or without chondroitin (1200 mg daily). Take it every day for 3 or 4 months without making other changes in treatment before you decide whether it’s working.
Don’t buy an expensive brand of glucosamine. The extra cost probably isn’t worth it.
Don’t take chondroitin without glucosamine, as it is unlikely to help.
Do apply ointments and rubs for pain relief. Start with capsaicin, which is available without a prescription. Buy the lowest strength you can find, and start by applying a very small amount on a small area because it may cause a burning sensation in the beginning. If you can’t tolerate capsaicin ointment, try a salicylate rub instead.
Do consider corticosteroid injections if you continue to have a lot of pain in your knee, especially if the doctor finds that you have fluid build-up. (If you don’t want to be injected with a steroid, ask your doctor if you’re a candidate for injections of hyaluronic acid, an artificial joint fluid that may help some patients.)
Do try TENS (transcutaneous electrical nerve stimulation) if you continue to have severe hip or knee pain. TENS therapy may be administered by a physical therapist, or with a device that you can use at home. A pad that emits a small tingle of electricity is placed over the painful joint to relieve the pain.
Do talk to your doctor about narcotic pain medication if your pain continues to be severe.
ADDITIONAL SELF-CARE TIPS:
Do try a wrap-around knee brace, which you can purchase at your local pharmacy. Ask your doctor about getting a cane or a walker if you need additional support.
Do alert your physician to certain conditions that can make your arthritis pain worse—insomnia, depression, or foot problems, for instance. And, if you have ill-fitting shoes or shoes that don’t provide much support, it’s time to replace them.