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Osteoarthritis: rational approach to treating the individual

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Osteoarthritis (OA) is the most common form of joint disease and the leading cause of pain and physical disability in older people. Risk factors for incidence and progression of osteoarthritis vary considerably according to the type of joint. Disease assessment is difficult and the relationship between the radiographic severity of joint damage and the incidence and severity of pain is only modest. Psychosocial and socio-economic factors play an important role. This chapter will discuss four main guiding principles to the management of OA: (1) to avoid overtreating people with mild symptoms; (2) to attempt to avoid doing more harm than good (‘primum non nocere’); (3) to base patient management on the severity of pain, disability and distress, and not on the severity of joint damage or radiographic change; and (4) to start with advice about simple measures that patients can take to help themselves, and only progress to interventions that require supervision or specialist knowledge if simple measures fail. Effect sizes derived from meta-analyses of large randomized trials in OA are only small to moderate for most therapeutic interventions, but they are still valuable for patients and clinically relevant for physicians. Joint replacement may be the only option with a large effect size, but is only appropriate for the relatively small number of people with OA who have advanced disease and severe symptoms. The key to successful management involves patient and health professionals working together to develop optimal treatment strategies for the individual.

Section snippets

The pathogenesis of osteoarthritis

OA is strongly age related, occurring more frequently in women than in men. The prevalence, as well as causal associations and outcomes of the condition, varies markedly according to the joint site affected (Table 1). Risk factors include an inherited predisposition, joint injury, obesity and selected activities.5 These associations, combined with the finding that the focal areas of joint damage tend to localize to areas of the joint that are most highly loaded, indicate that the disease

Diagnosis and assessment

Joint pain and the radiographic evidence of the joint pathology that characterizes OA are both very common in older people. For example, about 20% of people over the age of 35 years complain of current knee pain6, 7, and some 50% of these will have radiographic changes of OA in the knee joint.8 Not surprisingly then, most people over the age of 50 years presenting with regional joint pain in sites frequently affected by the condition (knees, hips, hands, feet and spine) are diagnosed as having

Principles of management

OA can occur in any of the approximately 200 synovial joints in the body. Management is, to some extent, site specific, and it is impractical to review the management of each joint site individually. This chapter will concentrate on the two sites that are most commonly a cause of severe pain and disability in the community, and for which the evidence is strongest, i.e. the hip and knee.

Symptomatic hip and/or knee OA are very common but often mild. In light of this and the background information

The evidence base

The management of OA needs to be based on sound evidence. Unfortunately, there is a paucity of evidence about the effectiveness of many of the interventions used.90 In order to help address that problem and to provide a framework for the discussion that follows on the various types of treatment available, a meta-analysis of the effects of several commonly used simple interventions on pain was performed.

Figure 3 presents an example of four meta-analyses of large randomized controlled trials

Education

Most of the treatment for OA is controlled by the patients themselves through self-management. Many people do not seek medical help at all, or if they do, look for advice and reassurance from single isolated visits. This means that the information provision, education and social support provided by professionals (both on a face-to-face visit, through the media and elsewhere) appears to be important, particularly as OA is a chronic condition that necessitates accommodation to altered function

Non-steroidal anti-inflammatory drugs

There are literally hundreds of trials on NSAIDs. They report effective pain relief in OA, but that long-term use is likely to result in gastrointestinal or other complications.38 The likely benefits in terms of pain reduction are moderate when compared with placebo (Table 4), and there is no robust evidence that any one NSAID is superior to another.39, 40 Similarly, there is no evidence indicating which patients should be treated with an NSAID rather than an analgesic. There is a small

Arthroscopic surgery

Arthroscopic surgery is one of the most commonly used surgical interventions for mild to moderate knee OA. Several different techniques are used, including simple lavage, debridement, abrasion, attempted repair of cartilage defects, and arthroscopic cartilage transplantation. This chapter will concentrate on the most common procedures, lavage and debridement, which are often combined. Several studies have claimed that these procedures are effective.67, 68, 69, 70 However, in a landmark trial,

Combining different interventions

The above comments about the individual interventions available are based on a comprehensive review of the trials literature. Nearly all reported trials have tested the efficacy of one single intervention, with tests of drugs outnumbering trials of non-pharmaceutical interventions considerably.90 However, in practice, combinations of pharmaceutical and non-pharmaceutical treatments are used; the general management of OA involves complex interventions or packages of care. Some recent work has

Other management issues

In addition to the three main categories of management described, physicians treating people with OA need to consider three other issues: flares, comorbidities and the use of complementary and alternative medicines.

Conclusions

OA is a major cause of pain and disability amongst older people in the general population. Many have relatively mild disease and the ‘patients’ themselves do much of the management. However, healthcare professionals are frequently called on to help relieve the pain, disability and distress that can accompany joint damage. Joint replacement may be the only option with a large effect size, but this is only appropriate for the relatively small number of people with OA who have advanced disease and

Acknowledgements

The authors are grateful to Mr Jiri Chard for his help in finding and reviewing the literature to help inform this article. This work was funded by the UK Medical Research Council and by the Swiss National Science Foundation's National Research Programme 53 (Grant Numbers 405340–104762 and 3200-066378). Peter Jüni is a PROSPER Senior Research Fellow funded by the Swiss National Science Foundation (Grant Number 3233-066377). Bristol is the lead centre for the MRC-HSRC.

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