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Osteoarthritis (degenerative arthritis or degenerative joint disease): A Nursing Perspective

1 Contact Hour including 1 Pharmacology Hour
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Thursday, February 23, 2023

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

This course is intended to provide the information necessary for a nurse to provide adequate nursing care for a patient with osteoarthritis, including understanding the disease, assessing the patient and helping the patient obtain optimal control over their disease.

Objectives

After completing this educational activity, the participant will be able to meet the following objectives:

  1. Discuss the burden of osteoarthritis (OA).
  2. Discuss national goals to improve the care of OA.
  3. Identify the risks for developing OA and the risks for progression of OA.
  4. Describe the nursing assessment in the evaluation of the arthritic patient.
  5. List five interventions that relieve symptoms and minimize disease progression.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Raymond Lengel (MSN, FNP-BC, RN)

Introduction

Osteoarthritis (OA) is the most common cause of disability in the older population. It is also known as degenerative arthritis or degenerative joint disease. Arthritis affects up to 54 million people and costs more than $140 billion annually in the United States. As the population ages, the burden of OA will increase (Healthy People, 2019). Managing arthritis improves mobility, decreases falls, decreases death rates and improves the quality of life.

Osteoarthritis is a joint disease with deterioration of the joint and abnormal bone formation. OA is present when the endings of the bones - called cartilage, which normally cushion the bones - no longer do their jobs. The ends of the bones rub together, and the cartilage wears away.

Two common types of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis is the more common type of arthritis in individuals over 50. Rheumatoid arthritis - a chronic destructive, sometimes deforming disease - attacks the collagen in the body, especially in the joints. Rheumatoid arthritis is associated with widespread symptoms such as fatigue, fever, poor appetite, neuropathy, splenomegaly and adenopathy. Other diseases that affect the joints include gout, lupus, scleroderma and fibromyalgia.

Immobility, a major complication of arthritis, leads to less activity which is associated with many complications, including worsening of joint stiffness, increased blood pressure, increased blood glucose and weight gain. Immobility leads to decreased physical activity - resulting in deconditioning. As deconditioning sets in, weakness and functional decline follow. This cascade that arthritis is associated with leads to a decreased quality of life. Lack of physical activity is detrimental to the body and increases the risk of many fatal diseases such as diabetes, high cholesterol, hypertension and heart disease.

Case Study Hand Osteoarthritis

Mr. Farmer is a 62-year-old white male who reports significant hand pain. He describes the pain as most severe in both thumbs and the distal joints of digits two through five of both hands. He has been increasingly having difficulty using his screwdriver to fix things around the house, playing tennis and golf, and griping his utensils to eat.

A physical exam shows an enlargement of the distal interphalangeal joints (Heberden's nodes) and the carpometacarpal (CMC) joints of both hands.

An x-ray demonstrates arthritis at the CMC joints of both hands and the distal interphalangeal joints of all fingers, as evidenced by cyst formation, sclerosis, and joint space narrowing.

The most common joint of the hand affected by OA is the distal interphalangeal joint, and the second most commonly affected joint is the CMC. The proximal interphalangeal and metacarpophalangeal joints are more commonly affected by rheumatoid arthritis.

The goal for the patient will be to reduce pain and help restore function. Treatment options for this patient include using finger or wrist splints, heat treatment, topical medications, occupational therapy to provide exercises, pain medication, steroid injections or surgery (joint fusion or joint reconstruction).

A Poorly Understood Disease

A knowledge gap exists in the prevention and management of osteoarthritis. A recent symposium of 40 health care leaders identified multiple problems with the way OA is managed.

This symposium looked at the top barriers to and strategies for improving OA's early assessment and treatment. It specifically discussed the nurse's role in reducing the disability caused by OA. Some of the barriers identified included items at the organizational level such as lack of provider time, lack of patient educational material, no reimbursement for an OA chronic disease model, and lack of financing for nursing intervention and nurse-managed care.

The symposium recognized three factors directly related to nursing knowledge deficit: lack of knowledge among nurse faculty and clinicians about OA best practices, lack of knowledge on how to promote disease self-management, and lack of knowledge about evidence-based practice in general.

Based on this knowledge deficit, the symposium made multiple recommendations to improve OA care. Many of these strategies revolved around improving nursing knowledge and the ability to disseminate this knowledge.

A significant gap exists among primary care providers between what is believed should be done and what is done. A recent analysis suggested that over 55 percent of general practitioners thought OA should be monitored, but only 15.2 percent routinely monitored their patients, and 45 percent did not monitor their patients at all (Clarson et al., 2014).

Another recent analysis showed a significant gap between what practices nurses feel confident in and what ideally should be performed according to the NICE OA guidelines (Healey et al., 2016). This analysis showed that properly educated nurses could lead OA clinics that significantly benefit patients with OA.

National Goals

Multiple organizations have goals to reduce the burden and help manage OA. Selected organizations working to lessen the burden of OA include the Center for Disease Control (CDC 2018), the Arthritis Foundation (2019), Healthy People 2020 (2019), and many state government organizations.

The goal of the CDC is to help people with arthritis live life to the fullest and help them pursue activities they value and enjoy with minimal pain (CDC, 2018b).

The main goals of the National Arthritis Action Plan: A Public Health Strategy are to:

  • Prevent arthritis
  • Increase public awareness
  • Assist in early diagnosis and treatment
  • Reduce pain and disability associated with arthritis
  • Help people develop self-management techniques to manage OA physically, psychologically and occupationally
  • Support patients and family members with arthritis suffer (Arthritis Foundation, 2018).

Healthy People 2020 provides objectives for the nation to reach with the overall goal of improving the national state of arthritis. The goals of Healthy People 2020 include:

  1. Reduce the mean level of joint pain among adults with diagnosed arthritis
  2. Reduce the proportion of adults with arthritis who experience a limitation in activity because of arthritis or joint symptoms
  3. Reduce the proportion of adults with arthritis who find it "very difficult" to perform specific joint-related activities such as walking a quarter of a mile, walking up steps, bending, kneeling, or grasping small objects
  4. Reduce the proportion of adults who have a difficult time performing personal care activities
  5. Reduce psychological distress in those with arthritis
  6. Reduce work-related complications such as unemployment or limitations in work due to arthritis
  7. Increase the proportion of those with arthritis who get counseling from their health care provider on items such as exercise and weight loss
  8. Increase the proportion of those with arthritis who receive evidence-based care
  9. Increase the proportion of adults who see their health care provider for chronic joint symptoms

The national goals are set to improve arthritis care. The first step in reaching these goals is improving the health care provider and patient knowledge.

In addition to the programs on the national level, many State Health Departments are working to improve the care of arthritis by increasing public awareness of the disease and improving the care of arthritis.

Causes of Arthritis

OA is characterized by osteophyte formation, changes in the subchondral bone, cartilage damage, inflammation of the synovial tissue and tendon and muscle weakness. OA is not only a disorder of the articular cartilage but also of the subchondral bone. OA is characterized by subchondral bone sclerosis and damaged cartilage. Subchondral bone is hypo mineralized secondary to abnormal bone remodeling. In addition, the subchondral bone may have microdamage, bone cysts and bone marrow edema-like lesions (Li et al., 2013).

Multiple factors contribute to OA (Lozada, 2018). Age is an important risk factor for the disease, with older individuals at greater risk than younger people. Females have a higher incidence of OA than males. Obesity is a strong risk factor due to the excess stress that extra body weight puts on the weight-bearing joints. Repetitive stresses, such as stresses on the joints by runners or assembly-line workers, increase the risk of arthritis. Weak muscles in the legs also contribute to OA. Trauma plays a significant role in the development of OA – as those with a history of trauma near a joint or a broken bone near a joint are at increased risk for OA. While no specific genetic marker is known in OA, there is a strong family connection. Defective cartilage or poorly structured joints commonly run in families and can increase the risk of osteoarthritis.

Risk Factors for Osteoarthritis
  1. Obesity
  2. Age
  3. Heredity
  4. Trauma
  5. Repetitive stress such as those who have played a lot of sports
  6. Occupations that have a lot of repetitive movements e.g. assembly line workers, carpet installers

Signs and Symptoms

The hallmark symptom of OA is pain. Typical OA pain is worse with movements and improves with rest. Pain at night is common, especially as the disease progresses, and is usually worse after a more active day. OA commonly affects the weight-bearing joints, such as knees and hips, but other joints commonly affected include the fingers (DIP and CMC) and neck. Stiffness after prolonged rest is common with this disease. For example, getting out of bed in the morning or getting up after watching a movie often elicits pain and stiffness.

A physical exam reveals certain characteristics that are typical of OA. Moving the joint results in a crackling/crunching noise that sounds like the cereal Rice Krispies and is known as crepitus. Arthritic joints are sometimes unable to move through a full range of motion. For example, a person with knee OA may not be able to straighten the leg fully.

Misalignment of the joints may be present and accompanied by enlargement of the bones surrounding the joint. The effusion may be noted, but rarely is there erythema over the affected joint.

Features of Osteoarthritis
  1. Pain in the joints that is worse with movement and improves with rest
  2. Common joints affected: knees, hips, fingers, neck and spine
  3. Usually only one to a few joints are affected
  4. Stiffness after prolonged rest such watching a movie or waking up in the morning
  5. Crepitus
  6. Decreased range of motion
  7. Swollen joints

Diagnosis

The diagnosis of OA is typically made with a history and physical exam. If in doubt, an X-ray is ordered. Diagnosis is specific to the joint affected (John Hopkins, 2018).

  1. Knee – knee pain plus three of the following:
    1. Boney enlargement of the knee
    2. Boney tenderness of the knee
    3. Over age 50
    4. Crepitus
    5. Morning stiffness lasting less than 30 minutes
    6. No warmth over the joint
  2. Hip – hip pain plus two of the following:
    1. Osteophytes on x-ray
    2. Joint space narrowing on x-ray
    3. Normal erythrocyte sedimentation rate OR (d, e, and f)
    4. Internal hip rotation associated with pain and internal rotation greater than/equal to 15 degrees
    5. Over age 50
    6. Morning stiffness less than 60 minutes
  3. Hand–hand pain plus three of the following:
    1. Boney enlargement of two or more DIP joints
    2. Boney enlargement of 3 or more of the 10 selected joints (2nd and 3rd DIP and PIP of both hands and 1st CMC of both hands)
    3. Less than three swollen metacarpophalangeal joints
    4. Deformity in at least one of the 10 selected joints

Laboratory tests alone do not diagnose OA but assist in the diagnosis and help rule out any other disease processes. If there is fluid in the joint, it may be removed. This procedure can help relieve some of the pressure associated with the excess fluid. The fluid is typically examined under a microscope to help rule out other diseases that mimic arthritis, such as gout.

Case Study

Mr. X is a 66-year-old carpet installer who has been retired for 10 years. He has been experiencing progressive pain in both knees, but the right knee is more bothersome than the left. Over the last two months, the pain has been less responsive to over-the-counter pain medications. He complains of his knees being stiff for approximately 30 minutes when waking in the morning and about five minutes after getting up from a seated position during the day. Walking for more than 30 minutes is difficult due to pain. Pain is increased with squatting, kneeling and going downstairs. He claims more severe symptoms on cold or very humid days. He decides to visit his nurse practitioner.

The patient is 5'9" and 225 pounds with a body mass index of 33.2. He was noted to walk with a slightly antalgic gait. The clinical exam shows boney enlargement and tenderness of both knees, and he cannot extend his right knee beyond 120 degrees but can fully extend the left knee. A slight genu varum of both knees suggests that the medial compartments of the knees are involved. Crepitus is noted in both knees, and tenderness is noted over the joint line in the knee. An x-ray shows joint space narrowing and medial osteophytes.

The nurse practitioner recommends weight loss, prescribes meloxicam and refers the patient to an orthopedic surgeon who recommends a total right knee replacement. Mr. X. only gets moderate relief with the meloxicam, but he does not want to proceed with the total knee replacement, so he asks what other options are available. The orthopedic surgeon discusses other treatment options, including lifestyle changes (exercise and weight loss), joint injections (corticosteroids and Intra-articular hyaluronic acid), medications and alternative treatments.

Treatment

Treatment of osteoarthritis focuses on pain control and maintaining function. Soon there may be treatments available to reverse or even cure the disease process, but symptom control is currently the only option. Treatment focuses on medications, and non-medication means controlling pain and minimizing disability.

Non-Pharmacological Treatment

Non-pharmacological treatment is first-line management as it bypasses drugs' negative effects on the body. Non-drug treatments include exercise, nutrition, physical and occupational therapy, heat and cold treatments, ultrasound, weight loss, magnets and patient education.

Weight loss can significantly reduce the pain and disability from OA by reducing the load that excess weight puts on the joints. Weight loss is accomplished through a combination of diet and exercise. Physical therapists or exercise specialists teach how to exercise safely while a dietitian aids with dietary interventions for weight loss.

Exercise can help OA in a variety of ways. Exercise decreases pain and improves functioning. It improves the strength of the muscles around the arthritic joint, reducing strain on the joint, resulting in pain control and improved function. Exercise can also aid in weight loss, a key element in reducing symptoms of OA.

Exercise needs to be tailored for those suffering from OA. Exercise that does not overly tax the arthritic joints is recommended. Exercises that limit strain placed on the joints commonly affected by OA include water exercise, such as water aerobics; bicycling, especially recumbent biking; and elliptical exercise equipment, which can be found at many gyms. Exercises that strain the joints, such as running and high-impact aerobics, are not recommended as they can damage the joints and cause more pain.

Recent research suggested that there is no difference between land-based and water-based exercise for the treatment of knee osteoarthritis (Dong et al., 2018).

Different types of exercises are important in the treatment of OA. Aerobic exercise - such as biking, swimming, walking and water aerobics - is important not only for the treatment of OA but also for general health. Flexibility training or stretching exercises reduce stiffness and help improve function. Strength training keeps the muscles strong to support the joints.

Diet and exercise are beneficial for OA. In a recent study over 18 months, there was a reduction in knee compressive forces in those who dieted and lost weight. Those who participated in both diet and exercise together (compared to those who just dieted or exercised) had less pain and better function (Messier et al., 2013).

Good nutrition is valuable in OA. Weight loss is a critical aspect in the prevention and treatment of osteoarthritis. While there is much media buzz about certain types of food being beneficial in OA, little research backs this up. Eating a diet low in saturated fats and high in fruits and vegetables is generally recommended. Omega-3 fatty acids, found in fish such as mackerel, herring, salmon and rainbow trout, are theorized to be helpful in OA (Knott et al., 2011). One meta-analysis showed that fish oil in 3 of 4 clinical trials had positive effects on at least one clinical marker of OA (Akbar et al., 2018). In addition, there is likely some benefit of the Mediterranean diet for individuals with OA (Morales-Iyorra et al., 2018). A recent analysis does not recommend the use of vitamin A, C, E, ginger, turmeric or omega-3 fatty acids in managing OA. More research is needed to define the role of supplements in OA management (Rosenbaum et al., 2010). Another meta-analysis showed that some supplements benefit short-term (including passion fruit peel extract, curcumin, L-carnitine, undenatured type II collagen, methylsulfonylmethane, glucosamine and chondroitin), but not as much benefit was noted in the long term (Liu et al., 2018).

Physical and occupational therapists can be extremely important in the treatment of OA. They can assist in strengthening the muscles, improving flexibility and providing non-drug means of pain control such as ultrasound or heat/cold treatments. OA profoundly contributes to disability, and improving the home environment promotes function and safety. Occupational therapists provide home assessments. Home assessments can help maximize the home's safety while implementing interventions to make the home safer. Bars in the bathroom, next to the toilet and in the shower or bathtub are examples of home interventions carried out by occupational therapists.

As OA progresses, mobility becomes increasingly impaired. Reliance on mobility aids – such as canes and walkers - becomes essential to ambulate. Physical therapists can help teach patients how to use canes, walkers, and other mobility devices.

Heat and cold treatments are helpful for patients with OA. Cold treatment decreases inflammation and reduces pain. It is best to apply cold in a moldable form such as a bag of frozen peas for no more than twenty minutes at a time and watch for any complications associated with the cold, such as any red or white patches on the skin or if the area becomes completely numb.

Heat is another common modality in the treatment of OA. Heat will increase the blood flow to the area, aid in healing and relaxes muscles. It should be used no longer than 30 minutes per application and should not be applied directly to the skin. While neither heat nor cold will modify the course of the disease, either is acceptable. Every modality provides more comfort, and pain relief should be used. Many patients find heat more soothing for their aching joints than cold. It is recommended that patients experiment to determine which intervention provides the greatest relief to their symptoms (Denegar et al., 2019).

Utilizing ultrasound has the potential to reduce pain in those with osteoarthritis. Ultrasound research is mixed. Research has shown that long-duration, low-intensity ultrasound improves the joint's function and lessens pain in those with moderate to severe knee arthritis (Draper et al., 2018). Another study looked at using ultrasound five times a week for two weeks in addition to exercise training. The study concluded that therapeutic ultrasound offered no additional advantage in improving pain and function in addition to exercise training (Cakir et al., 2014).

Magnets are a popular therapy for OA because they can decrease pain. Scientific data to prove their effectiveness is lacking, but magnets do not have significant side effects and are considered safe for use. Magnets are sold in various places, including pharmacies, grocery stores, online, and on TV. Current research does not support the use of static magnets for pain relief. More research is needed before their use in OA is completely disregarded.

Drug therapy

Medications are used to treat OA when non-drug methods do not provide adequate relief. Previous guidelines touted acetaminophen (Tylenol) as a first-line agent, primarily due to its lack of negative side effects (compared to nonsteroidal antiinflammatory medications), but more recent guidelines refute this recommendation.

Two extra-strength acetaminophen tablets every eight hours is the maximum dose recommended. The maximum amount of acetaminophen is three grams a day. It can be taken on a routine basis or on an as-needed basis. Prolonged use of acetaminophen in higher than recommended doses or when combined with alcohol or certain medicines such as statins (e.g., atorvastatin, simvastatin) can damage the liver.

Caution should be used in patients who take acetaminophen when they are on warfarin. The combination of acetaminophen and warfarin can increase the INR (but less than nonsteroidal antiinflammatory agents). Absolute contraindication to acetaminophen is a liver failure, while relative contraindications include chronic alcohol abuse or hepatic insufficiency.

The American Academy of Orthopaedic Surgeons (AAOS, 2018) does not recommend for or against using acetaminophen. Their position paper reports that acetaminophen has no benefit over placebo. Others recommend that acetaminophen is the least effective option compared to NSAIDs or the combination of glucosamine and chondroitin (Zhu et al., 2018). They do acknowledge that the side effect profile of acetaminophen is less toxic than nonsteroidal antiinflammatory agents (NSAIDs). NSAIDs are considered more effective than acetaminophen in relieving hip and knee pain in osteoarthritis (Lozada, 2018). Like acetaminophen, they act synergistically with opioids.

NSAIDs, such as ibuprofen (Motrin, Advil), naproxen sodium (Aleve, Naprosyn), choline and magnesium salicylates (Trilisate), diclofenac sodium (Voltaren, Voltaren XR), celecoxib (Celebrex), meloxicam (Mobic), and nabumetone (Relafen), are recommended over acetaminophen (McAlindon et al., 2014).

These medications have more side effects than acetaminophen. Side effects common to NSAIDs include hypertension, edema, gastrointestinal bleeding, dyspepsia, headaches, constipation, mental status changes and renal insufficiency/kidney failure.

Absolute contraindications to NSAIDs include chronic kidney disease, an active peptic ulcer, and heart failure. Relative contraindications include a Helicobacter pylori infection, a history of peptic ulcer disease, hypertension, or concomitant use of selective serotonin receptor inhibitors or corticosteroids. Common interactions with NSAIDs include aspirin, warfarin, antihypertensive medications, selective serotonin reuptake inhibitors and corticosteroids.

Risk factors for gastric ulceration include older age, current use of corticosteroids, bleeding problems, or a history of gastric ulceration. These individuals should likely not use NSAIDs. The use of a proton pump inhibitor or misoprostol reduces the risk of gastric ulceration with the use of NSAIDs.

Another option for those with risk for gastric ulceration is using celecoxib. Celecoxib is the only available selective inhibitor of cyclooxygenase (COX) -2. COX-2 inhibitors are less likely to lead to gastric irritation. In those at very high risk for gastrointestinal bleeding, a COX-2 agent along with a proton pump inhibitor can be used. Monitoring for and eradicating Helicobacter pylori reduces the risk of NSAID-induced gastrointestinal injury.

NSAIDs can potentially cause nephrotoxicity because they inhibit prostaglandin synthesis, which is associated with vasoconstriction of the afferent arteriole in the kidney and may lead to renal impairment. Compared to traditional NSAIDS, celecoxib has a lower risk of GI bleeding (Shin, 2018).

NSAIDs are associated with cardiovascular complications. They interfere with the cardioprotective effect of aspirin (Gladding et al., 2008), elevate blood pressure and may precipitate or aggravate heart failure. NSAIDs also may amplify the risk of clotting and need to be used cautiously in those with a history of venous thrombosis. They should also be avoided in those with thrombocytopenia.

Generally, NSAIDs are equally effective (Roelofs et al., 2014), but if one agent is ineffective, another NSAID may be effective as there is individual variation in response to different NSAIDs. One study showed that 150 mg/day of diclofenac was the most effective NSAID in managing pain and improving function (Da Costa et al., 2017).

Topical NSAIDs may be used, especially if the disease is localized to one area. Topical agents are associated with a significantly less adverse event profile than systemic agents. In the United States, diclofenac sodium topical gel and diclofenac sodium topical solution is available to manage osteoarthritis.

Other topical agents can provide significant relief for patients with OA. Capsaicin (Zostrix) decreases the neurotransmitter called substance P, which is involved in the transmission of pain. Capsaicin is applied three to four times a day. It takes Capsaicin a few weeks before it provides significant pain relief. Hands should be washed after contact with the substance.

Another topical agent sometimes used to treat localized pain is the lidocaine patch. This patch is not approved by the Food and Drug Administration for use in OA but is often used. It is a small patch applied to the skin around the painful joint and worn for no more than 12 hours daily.

Other agents used in the treatment of osteoarthritis include duloxetine and hydroxychloroquine. The Food and Drug Administration does not approve these agents for OA. Duloxetine is sometimes tried in those who do not respond to or have contraindications to NSAIDs. Research has shown that these agents result in some improvement in function and a reduction in pain but are associated with significant side effects, including fatigue, dry mouth, constipation, reduced appetite and nausea. Duloxetine has only been studied in OA in the short term (up to 13 weeks) (John Hopkins, 2018).

Hydroxychloroquine is theorized to reduce synovitis and possibly help patients with hand arthritis. While it may be helpful in some individuals, research does not show it significantly improves symptoms of hand arthritis (John Hopkins, 2018).

Tramadol (e.g., Ultram®, Ultram® ER) is dosed 50-100 mg every 4-6 hours for the immediate release form and 100 mg daily for the extended-release form. For individuals suffering from chronic arthritic pain, the immediate release is initiated at 25 mg in the morning and increased by 25-50 mg daily every three days. The maximum dose for the immediate release form is 400 mg per day. The extended-release form starts at 100 mg once a day and increases by 100 mg every five days with a maximum dose of 300 mg daily. Side effects include constipation, dizziness, nausea, vomiting, euphoria, headache, itching, agitation, somnolence, hallucinations, and anxiety.

Tramadol interacts with narcotic medications and many antidepressants. It should be used carefully for those with moderate to severe renal insufficiency or severe liver insufficiency. Tramadol lowers the seizure threshold and should, therefore, be used cautiously in those with a history of seizures. Caution must be used with tramadol as it has abuse potential.

Narcotic medicines are used when pain cannot be controlled by other means. They should only be used on a time-limited basis in those with disabling symptoms or severe pain that have not responded to other treatment modalities. Before starting opioid therapy, it is important to determine the effect the pain has on the patient's life, including functional ability and psychological impact. Narcotics are more powerful pain medications but have side effects. Narcotics have the potential side effects of sedation, respiratory depression, dizziness, falls, constipation, addiction and dependence. Narcotic medications include codeine, hydrocodone, hydromorphone, oxycodone, fentanyl, and morphine.

Injectable Therapy

Intra-articular steroid injections can be used for painful joints. This injection involves placing a needle directly into the arthritic joint and injecting a steroid and a numbing agent. Prior to administration of the medication, aspiration of synovial fluid may occur. These can be effective treatments, but their length of effect is variable from weeks to months. Reduction in pain may occur as soon as one week after the injection. Corticosteroid injections have the potential to damage cartilage, and no more than three injections per year should be given (John Hopkins, 2018).

Intra-articular hyaluronic acid is sometimes used to mimic the joint lubricant, which is often reduced in those with OA that naturally occurs in the knee. It is classified as a medical device and not a drug. Products include Hyalgan, Supartz, Orthovisc, Euflexxa, and Synvisc. The use of hyaluronic acid is of uncertain benefit.27 In addition, the cost can be prohibitive and side effects include pain and rarely joint infection.

Platelet-rich plasma (PRP) is a newer treatment option for osteoarthritis. It involves intraarticular injections. An analysis of the randomized controlled trials on PRP (Bennell et al., 2017) concluded that it was a relatively safe procedure and likely provided some benefit for up to 12 months. Those individuals with severe diseases and younger age respond better to treatment. Many questions remain, including how many injections it takes to be effective, the length of time between injections and the volume needed to be injected. Evidence regarding this treatment is limited and more research is needed before it is routinely used. In addition, insurance companies typically do not pay, which tends to be an expensive treatment.

Surgery

When medical treatment fails, surgery is the next option. Surgical options include arthroscopy, osteotomy, total joint arthroplasty, or joint fusion. In OA, arthroscopy can remove meniscal tears and loose bodies. Success rates are variable after surgery. After arthroscopy, the patient often needs to be non-weight bearing for a while and may need to undergo physical therapy.

When the surgeon removes a wedge of bone, an osteotomy may be used to stave off joint replacement in younger patients to reduce pain. It can be used for misaligned hip or knee conditions such as genu varus or genu valgus.

Joint replacement surgery replaces the damaged joint with an artificial one (plastic or metal). Even under the best circumstances, surgery cannot return the joint to its normal state (artificial joints do not have all the motion of a normal joint). However, an artificial joint will very likely diminish pain and improve function. Typically, the artificial joint is viable for at least 10-15 years. The two most commonly replaced are the hip and knee joints. Complications after surgery include infection, thrombophlebitis and pulmonary embolism.

A joint fusion is the joining of the bones on each side of the joint. The range of motion is significantly reduced, but the pain is improved. Fusions are typically not a first-line procedure for knee or hip arthritis but are sometimes used when a joint arthroplasty fails.

Conclusion

Osteoarthritis is a common condition, particularly in the older population. It is characterized by pain and disability. Diagnosis is typically made based on signs and symptoms, but diagnostic testing may be done when the clinician is uncertain. Multiple treatment options are available, ranging from lifestyle changes to surgery.

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