When it comes to treating knee arthritis you may have more options than you realize. In March 2014, the Osteoarthritis Research Society International (OARSI), a nonprofit organization dedicated to promoting rthritis research and treatment, updated its recommendations for the treatment of rthritis targeted to different patient characteristics. A group of 13 experts from around the world reviewed the latest research on OA treatments as the framework for the revised guidelines. OARSI published its first guidelines in 2008.
Four groups of patients identified in the new guidelines are:
- Patients with arthritis in one or both knees only and no co-existing conditions such as diabetes, high blood pressure, cardiovascular disease, kidney failure, GI bleeding, depression or obesity.
- Patients with knee-only arthritis who have co-existing conditions
- Patients with multi-joint arthritis (hip, hand, etc.) and no co-existing conditions
- Patients with multi-joint arthritis who have co-existing conditions
Education and self-management. Many organizations, including the National Institute of Health and Clinical Excellence (NICE) and American Academy of Orthopaedic Surgeons (AAOS), recommend patients learn all they can about their arthritis and its treatment. However, one study found that a self-management course did little to improve pain, stiffness or physical function. Researchers have suggested that group educational sessions and telephone-based advice might be helpful, but another study questioned the practicality of these interventions.
Exercise. A variety of exercises, such as strength training, aerobics, range of motion and tai chi, can help with both pain and physical function in knee OA. Strengthening can also help with hip arthritis pain. Water-based exercises may improve function in both knee and hip joints, but offer only minor benefits for pain.
Weight loss. A 2007 review found reductions in pain and disability in previously overweight patients with knee OA who lost a moderate amount of weight. The recommendation is to aim for a weight loss of 5% within a 20-week period for the treatment to be effective. The benefits of weight loss on hip arthritis have yet to be proven.
Acupuncture. A form of traditional Chinese medicine involving the insertion of thin, sharp needles at specific points on the body, acupuncture has been touted as a treatment for osteoarthritis pain. A recent analysis of 16 randomized controlled trials found acupuncture was better than sham treatment for relieving OA pain. However, the effect didn’t reach the threshold for clinical significance. The recommendation is “uncertain.”
Balneotherapy. The new guidelines for the first time evaluated the use of balneotherapy, a treatment that involves soaking in warm mineral springs. It was found to be an “appropriate” therapy for people with multi-joint OA and co-existing conditions, who have few other treatment options.
Transcutaneous electrical nerve stimulation (TENS). A technique in which a weak electric current is administered through electrodes placed on the skin, TENS is believed to stop messages from pain receptors from reaching the brain. A recent study found that TENS didn’t relieve pain better than a sham procedure. While it’s uncertain whether TENS can help with knee-only OA, it’s not appropriate for OA in multiple joints.
Knee braces, sleeves, and other devices.One review found knee braces and foot orthoses helpful for reducing pain and joint stiffness and improving function in knee OA, without causing any adverse side effects. The new guidelines recommend using these sassistive devices as directed by a specialist.
Canes and crutches. Using a cane may reduce pain and improve function in people with knee OA. However, while it takes the load off the knee, it can add more weight onto other affected joints, such as the hip. There isn’t any evidence that crutches are a good alternative to the cane.
Acetaminophen (Tylenol). Several guidelines recommend acetaminophen as a first-line treatment of mild-to-moderate pain from knee and hip OA. However, because of concerns about risks such as ulcers, GI bleeding, and loss of kidney function in long-term users, current guidelines recommend limiting the dose and treatment time. For people with existing medical conditions such as diabetes, high blood pressure, cardiovascular disease, GI bleeding or kidney failure, the recommendation on acetaminophen is “uncertain.” (According to the committee, an “uncertain” recommendation doesn’t mean you should necessarily avoid the treatment; only that you should discuss it with your doctor and only use it when appropriate for you.)
Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications (aspirin, ibuprofen, naproxen sodium) are another option for pain relief. However, the risk of GI side effects such as ulcers and bleeding is also higher with NSAIDs than with acetaminophen. NSAIDs are also associated with cardiovascular risk and kidney damage. The panel recommends “conservative dosing and treatment duration consistent with approved prescribing limits.” In people at moderate to high risk of GI side effects, the committee recommends adding a stomach-protective drug called a proton pump inhibitor (PPI) while taking NSAIDs. However, people at high risk for side effects like cardiovascular disease or GI bleeding are advised to avoid using NSAIDs entirely.
Topical NSAIDs. These rub-on products may be as effective as oral NSAIDs, but they pose less risk of GI problems. And though topical NSAIDs can cause skin irritation, they’re considered a safer option than oral drugs. Topical NSAIDs are recommended for people with knee-only OA. For those with OA in other joints, the recommendation is “uncertain.”
Diacerein. This slow acting drug may slow cartilage breakdown in people with OA. A 2010 analysis found a small benefit for pain relief compared to placebo, but the drug also increased the risk for diarrhea. Though diacerein may be safer than NSAIDs, more high-quality studies are needed to confirm its effectiveness. For now, the recommendation is “uncertain.”
Duloxetine (Cymbalta). This antidepressant, which was evaluated for OA for the first time in these guidelines, may help with chronic pain. However, side effects like nausea, dry mouth, fatigue, constipation, and increased sweating may keep some people from taking it. Duloxetine is appropriate for people with OA of the knee and other joints. Whether people with knee-only OA and coexisting health conditions should take it is uncertain.
Capsaicin. This analgesic, which is derived from chili peppers, is better than placebo at reducing pain, but it can cause side effects such as a burning sensation or skin redness. It’s appropriate for knee-only OA in people without existing health conditions, but uncertain in people with multi-joint OA and those with health conditions.
Opioid and narcotic analgesics. A review of 18 randomized controlled trials showed a significant reduction in pain, and some improvement in physical function with the use of these strong pain relievers. However, these benefits were countered by significant side effects, including nausea, constipation, dizziness, sleepiness, and vomiting. Overall, about a quarter of patients treated with opioids—and particularly with strong drugs like oxycodone and oxymorphone—dropped out of studies because of side effects. The recommendation on both oral and patch forms of opioid pain relievers is “uncertain.”
Corticosteroid injections. Injecting corticosteroid compounds directly into affected joints can be useful for decreasing pain in the short term, although the effect tends to wear off after a few weeks. To maintain relief, you may need to have corticosteroid injections in the same joint every few months, or use another treatment.
Hyaluronic acid injections. Hyaluronic acid is meant to supplement a natural substance that gives joint fluid its viscosity. Most of the studies conducted have been in patients with knee OA. Although the study outcomes differ, some do find the treatment relieves pain. Hyaluronic acid injections seem to reach their peak benefit 8 weeks after the shot is given, and the effect lasts for about 24 weeks. Side effects were minimal, including temporary pain and swelling at the injection site. Because of inconsistent study results, hyaluronic acid injections are “not appropriate” for people with OA of the hip and other joints, and “uncertain” for those with knee-only OA.
Risedronate (Actonel). This bisphosphonate drug is better known for treating osteoporosis, but it may also reduce cartilage degeneration. More studies are needed to determine whether risedronate helps with symptoms, function, or OA disease progression. For now, the drug is deemed “not appropriate.”
Avocado soybean unsaponfiables. This extract made from avocado and soybean oils blocks pro-inflammatory chemicals and may help regenerate normal connective tissue. A 2008 review comparing this supplement with a placebo found it had a small benefit in reducing pain, particularly in people with knee arthritis. The recommendation is “uncertain.”
Joint lavage and arthroscopic debridement. The roles of joint lavage (flushing the joint with a sterile saline solution) and arthroscopic debridement (the surgical removal of tissue fragments from the joint) are controversial. Some studies have shown that they provide short-term relief; however, a 2008 Cochrane review suggested that in people with OA, arthroscopic debridement probably does not improve pain or ability to function compared to placebo (sham surgery).
Osteotomy and joint-preserving surgery. For young, active people with hip or knee osteoarthritis, osteotomy (a procedure in which bones are cut and realigned to improve joint alignment) may delay the need for joint replacement. A 2007 Cochrane review that included 13 studies found some evidence that high tibial osteotomy for knee OA helped reduce pain and improve function. An earlier study found the average time between this procedure and joint replacement surgery was six years.
Unicompartmental knee replacement. Approximately 30 percent of people with knee osteoarthritis have disease that is largely restricted to one area of the joint. In these cases, unicompartmental knee replacement (also called partial knee replacement) may offer the same improvement and function as total knee replacement but with less trauma and better range of motion. A 2007 review that compared unicompartmental knee replacement with total knee replacement found a similar improvement in function, but fewer complications and less need for revision surgery after unicompartmental surgery.
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