Osteoarthritis Is Not Just a Disease Caused By Wear and Tear

Are you a physician with a busy practice? Do you tend to medicate rather than educate patients with arthritis? Are you a patient with osteoarthritis? Would you rather be educated than medicated? If you fall into either of these categories, then the information in this article is for you.

The authors of this article make it clear that their goal is to help physicians provide thorough but efficient management of osteoarthritis (OA). But today's busy consumers who happen to have osteoarthritis are also interested in this information. Armed with the knowledge we have about osteoarthritis, you will be able to discuss these points with your physician.

Forming a plan of care that is evidence-based, complete, and do-able is an essential part of managing osteoarthritis. It starts with an accurate diagnosis and the understanding that osteoarthritis isn't just wear and tear on the joints.

Scientists have come to see that the joint is like an entire organ system in its own right. It is a very complex organ with multiple different structures like synovium, bone, nerves, muscles, and blood supply. There are mechanical parts and there is a neurologic road map to provide movement of those mechanical parts.

There are a few basic things that haven't changed in our understanding of this disease. First, age is the biggest risk factor. The older you get, the greater your chances for developing this condition. Second, the joints affected most often are the large ones: hips, knees, hands, and sometimes shoulders.

The symptoms tend to be the same no matter what joint is involved: pain, decreased joint movement, morning stiffness that gets better after 30 minutes of gentle movement, joint tenderness, and decreased function. There are certain risk factors that point to osteoarthritis as the cause of these symptoms including trauma, surgery, repetitive use or excessive use (usually work-related), and family history.

Your physician will rely on three tools when making the diagnosis: clinical findings, imaging studies (usually X-rays), and lab results. Many times, your verbal report of what's wrong is enough to make a diagnosis. X-rays can be helpful to guide treatment but aren't always necessary. Taking a sample of the fluid from inside the joint (called synovial fluid) may provide some additional clues.

The American College of Rheumatology has specific criteria physicians use to make the diagnosis for hand, hip, or knee osteoarthritis. They have updated their traditional format for diagnosis based on continued evidence from studies. Now they use a technique called the tree format.

The tree format combines various symptoms to determine how likely it is the patient has osteoarthritis (OA) of the joint in question. For example, when diagnosing hand osteoarthritis, instead of looking for hand pain, aching, or stiffness plus some other determining factors (the traditional format), now they look for hand pain, aching, or stiffness AND specific other clinical findings (tissue enlargement, deformity, swelling). Similar changes have been made for the diagnosis of hip and knee OA.

The idea of treatment of osteoarthritis has really been replaced with the notion that it is a disease that is managed. That means there isn't one single treatment for everyone. It's more of a plan that involves multiple different approaches.

Today's research evidence calls for a nonpharmacological approach first. Simply stated, that means "without drugs". This approach requires more time to educate the patient about the process and about his or her choices and responsibilities. There is much less focus on a magic pill to cure-all.

More and more, patients are being called upon to be proactive for themselves. They are encouraged to learn about the disease and find ways to protect their joints. But patients don't have to do this all alone. A team approach is advised with orthopedic surgeon, primary care physician, and physical and occupational therapists to offer advise, counsel, and guidance.

Some of the tools shown to make a difference include various types of joint braces, shoe inserts or shoe modifications, supportive neoprene sleeves, exercise, and weight loss. Modalities such as heat, cold, electrical stimulation, and acupuncture can be helpful during acute flare-ups. Assistive devices such as a walking stick, cane, or walker may be helpful to off-load the joint and protect the joint surface from further damage.

When medications are indicated, acetaminophen (Tylenol) is the first choice. When used as directed, it is a safe and effective pain reliever. Acetaminopehn does not have any antiinflammatory effects. There is a danger of liver damage with too much acetaminophen so patients must be advised carefully and monitored closely to prevent any adverse effects from occurring.

Other medications can be used if acetaminophen in combination with the management program isn't enough to reduce pain and improve function. These include nonsteroidal antiinflammatory drugs (NSAIDs), capsaicin (topical agent rubbed on the skin to produce a counter irritant), steroid injections, hyaluronic acid injections, and glucosamine and chondroitin sulfate (supplements).

If nothing works and the patient is still experiencing intolerable pain, then narcotic pain relievers may be prescribed or surgery may be recommended. In the case of severe knee osteoarthritis, there are several different surgical procedures that might help before going to a full joint replacement. Joint alignment can be corrected with an osteotomy (removing a wedge-shaped piece of bone to shift the weight bearing load). Or a unicompartmental replacement is possible (just replacing the side of the joint that is affected).

In summary, osteoarthritis is more than just a disease of wear and tear. The entire joint complex is involved with advancing age and multiple other risk factors as part of the picture. Treatment should be a program of self-management directed by a team of health care professionals.

Patient education and nonpharmacologic treatment are the first steps. The goal is to preserve and protect the joints while maintaining motion and function. It's not that medications can't be used -- they just shouldn't be the first thing patients are given. There's plenty of evidence that the approach described here for osteoarthritis works well and prevents unnecessary exposure to drugs and surgery.

Reference: J Chao, MD and Kenneth Kalunian, MD. Managing Osteoarthritis: A Multidisciplinary Approach. In The Journal of Musculoskeletal Medicine. October 2010. Supplement. Pp. S6-S12.

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