Various osteoarthritis treatments are recommended to patients with joint pain, stiffness, swelling, and other osteoarthritis symptoms. Patients are often confused by so many treatment options though -- and quite honestly, they would like to skip what doesn't work and focus on what does. Which osteoarthritis treatments are best?
Osteoarthritis Research Society International (OARSI) formed a committee (11 rheumatologists, 2 primary care physicians, 1 orthopedic surgeon, and 2 experts on evidence-based medicine from 6 countries) who performed a systematic review of treatment guidelines that existed from 1945 to January 2006 for knee and hip osteoarthritis. From the search, the committee identified 23 treatment guidelines for management of knee and hip osteoarthritis -- 6 were opinion-based, 5 were evidence-based, and 12 based on both expert opinion and research evidence. Through an arduous process that included critical appraisal of existing guidelines, systematic review of more recent evidence, and exercises to generate consensus recommendations -- ultimately 25 treatments were proclaimed "a single set of up-to-date recommendations."
Each recommended treatment was assigned an SOR (strength of recommendation) score. The SOR for each treatment was based on opinions of the guideline committee after considering research evidence for safety, effectiveness, and cost-effectiveness. The clinical expertise of the committee members helped formulate the SOR too, including such factors as their perception of patient tolerance for the treatment. The SOR is expressed as a percentage that represents the committee's consensus that the treatment is actually effective. For example, 97% indicates that the committee of experts feel there is a 97% chance the treatment is effective and supported by scientific evidence.
OARSI emphasized that optimal treatment for osteoarthritis involves both pharmacologic (drug) and non-pharmacologic (non-drug) treatments. That was the first general recommendation. The other 24 recommendations were divided into three categories -- nonpharmacologic, pharmacologic, and surgical. Next to each recommended treatment is the SOR percentage.
11 Nonpharmacologic Modes of Treatment for Osteoarthritis
- education about objectives of treatment and self-management through lifestyle modifications (97%)
- aerobic, muscle-strengthening, and water exercise (96%)
- weight reduction (96%)
- walking aids (90%)
- referral to a physical therapist (89%)
- footware and insoles (77%)
- knee braces (76%)
- regular telephone contact (66%)
- thermal modalities/heat (64%)
- acupuncture (59%)
- transcutaneous electrical stimulation (58%)
8 Pharmacologic Treatments for Osteoarthritis
- Oral NSAIDs (93%)
- acetaminophen (92%)
- topical NSAIDs and capsaicin (85%)
- weak opioids and narcotic analgesics for refractory pain (resistant to ordinary treatment) (82%)
- intraarticular (into the joint) injections of corticosteroids (78%)
- intraarticular injections of hyaluronan (64%)
- glucosamine and/or chondroitin sulfate for symptom relief (63%)
- glucosamine sulfate, chondroitin sulfate, and/or diacerein for possible improvement in joints and surrounding structures (41%)
5 Surgical Treatments for Osteoarthritis
- total joint replacement (96%)
- unicompartmental knee replacement (76%)
- osteotomy and other surgical procedures to preserve joints (75%)
- joint fusion after joint replacement has failed (69%)
- joint lavage (wash out) and arthroscopic debridement in knee osteoarthritis (60%)
Older guidelines for the treatment of osteoarthritis were developed prior to NSAIDs being scrutinized for potential heart risks (heart attack and stroke). The association of gastrointestinal side effects and heart risks has caused NSAIDs to be used less. OARSI committee members believe NSAIDs are effective anti-inflammatory drugs and that short-term use may be appropriate -- when considered on an individual basis. OARSI does not recommend NSAIDs for long-term use without considering a patient's history.
Overall, there were limitations of the guideline development by OARSI. One could point to the imbalance of doctors on the committee -- with orthopedic surgeons and primary care doctors underrepresented. Certainly one could point to the heavy subjectivity that was involved in developing a consensus. But even so, there is value in the new guidelines, especially for patients, who lack access to all of the previous guidelines that were considered by the committee.
Osteoarthritis: Which Treatments Work and Which Don't? Osteoarthritis Research Society International (OARSI). February 15, 2008.
OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage. W. Zhang et al. February 2008.