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Introduction

Osteoarthritis is one of the more than 120 forms of arthritis which can occur in patients. Osteoarthritis, also known as OA, osteoarthrosis, or degenerative joint disease (DJD), is the type of arthritis that almost everyone develops in their lifetime. It is a form of arthritis that develops gradually, usually occurring sometime after the age of 45. OA is usually chronic in nature but fortunately occurs most frequently as a relatively mild condition. Some patients, however develop more severe symptoms requiring treatment and even joint replacement.


OA - The Five W's - Who What Where When Why

Who develops osteoarthritis?

  • Osteoarthritis is seen in both males and females in a 3:2 female/male ratio. Occurrence is usually noted between the ages of 45-90, and affects more than 20.7 million Americans today.

What exactly is osteoarthritis?

  • Osteoarthritis is the type of arthritis involving the cartilage of a joint. The cartilage of a joint is a tough, gristle-like material which is found on the ends of the bones. It forms the surface of the joint on either side. Cartilage is durable and somewhat elastic. It does not have a blood supply and therefore gets its oxygen from the joint fluid surrounding it. When you use a joint, fluid and waste products are removed from the cartilage by the pressure involved. When pressure is relieved, oxygen and other nutrients are returned to the cartilage. Cartilage also has no nerve supply. It is this characteristic that allows large forces to be transferred without pain. Over time, the cartilage may become worn. The bony surface of the joint may begin to grate against the bone on the other side and the elasticity of the cartilage may be decreased. Eventually the cartilage may wear away entirely. This cartilage deterioration is, in fact, what defines osteoarthritis. Unlike some other types of arthritis, OA does not affect the whole body. However, the changes which it can cause may limit patients due to pain and loss of movement.

Where does OA occur?

  • OA can occur in any joint and may occur only on one side of the joint. Usually it is seen in the joints of the fingers, spine, hips, and knees. These joints fall into three common types of osteoarthritis(1). The first and usually mildest is the OA which affects the hands, causing knobby enlargement of the finger joints. When this occurs at the end joints of the fingers, these enlargements are called Heberden's nodes. Growths in the middle of the fingers are called Bouchard's nodes. This type of OA may cause stiffness and changes in the cosmetic appearance of the hand.
  • The second type of OA involves the spine. This can involve the neck area as well as the back. Bone spurs are symptoms of arthritis not necessarily the cause of pain.
  • The third type of OA commonly seen involves the weight-bearing joints, most frequently the hips and knees. This form of OA can become quite severe and limiting, or may only periodically cause symptoms. In extreme cases walking may become extremely difficult or impossible. This type of OA frequently involves both sides of the body, and may cause a deformity in the lower extremity due to the degeneration process.

When does OA occur?

  • OA can develop as a natural process of aging or it may occur as a result of a traumatic injury such as a fracture. Patients who have a congenital malformation of a joint also tend to develop OA at an earlier age than normally seen.
  • A common idea in past years was that osteoarthritis developed because of "wear and tear" or over-use of a joint. Research studies of people who participate in strenuous activities have failed to show a relationship between these activities and the development of arthritis. Furthermore, most experts agree that a patient, even when diagnosed with OA, needs to continue a program of exercise to maintain optimal function of the joint.

Why does OA occur?

  • No one knows for sure what causes osteoarthritis. Some experts believe that people are born with defective cartilage or abnormalities in their joints which lead to the changes seen in OA. Others believe that OA develops as a result of over-using an already injured joint or because of joint damage caused by other arthritic conditions. Research into the causes, prevention, and treatment of OA as well as other types of arthritis continue to provide improved methods for the relief of symptoms and will continue to aid in the understanding of these disease processes.

Diagnosis

  • As mentioned earlier, there are over 120 types of arthritis. Correctly diagnosing the type of arthritis a patient has may take several visits to a physician and perhaps a referral to a rheumatologist, a physician who specializes in the diagnosis and treatment of people with various forms of arthritis. While OA can be slow to cause any noticeable symptoms, once symptoms occur it is important that a physician be involved in your care. By seeking medical attention early, you may prevent or decrease serious joint damage. You also will be able to work with your physician in developing a treatment plan which is individualized for your needs and tailored to your lifestyle.
  • Signs and symptoms of osteoarthritis can be difficult to assess, however, it is important to make a diagnosis of OA correctly to ensure the optimum treatment plan. The American College of Rheumatology has established guidelines for the diagnosis of OA2. These guidelines, included in Table 1 and Table 2 establish the classification criteria as well as the signs and symptoms of OA. As indicated by these tables, diagnosis is based on patient history and exam, blood tests, and x-rays. Certainly if you or a family member are demonstrating any of these symptoms you should strongly consider a formal visit to your physician.

 
Table 1. Classification criteria for osteoarthritis

In the hip (3,4)

Hip pain and at least 2 of the following:

  • Erythrocyte sedimentation rate <20 mm/hr
  • Radiographic femoral or acetabular osteophytes
  • Radiographic joint space narrowing

In the knee (3,5)

Knee pain and radiographic osteophytes and at least 1 of the following:

  • Age >50 yr.
  • Morning stiffness <30 min in duration
  • Crepitus on motion

Brunton S, ©1998, by The McGraw-Hill Companies, Inc.

 
 Table 2. Signs and symptoms of osteoarthritis (3)
 Symptoms
  • Joint pain
  • Morning stiffness
  • Gel phenomenon
  • Buckling or instability
  • Loss of function
Signs
  • Bony enlargement
  • Limitation of range of motion
  • Crepitus on motion
  • Tenderness on pressure
  • Pain on motion
  • Joint effusion
  • Malalignment and/or joint deformity
 Brunton S, ©1998, by The McGraw-Hill Companies, Inc.

Treatment

Treatment of osteoarthritis has two goals as its main objectives. The first goal is to decrease the pain and discomfort you may be experiencing. The second goal is to decrease any disability you may have.

Methods of treating osteoarthritis vary according to each individual's needs. In some cases non-pharmacological treatment may be started, with the patient educated in physical and occupational therapy programs to achieve the goals of decreasing pain and disability. More involved cases of osteoarthritis may require pharmacological management with regular monitoring by your physician as well as physical and occupational therapy programs. In several cases, especially those involving the weight bearing joints, surgery may become necessary to decrease the pain and disability.

Goals: Treatment of osteoarthritis has three goals:

  • Decrease of pain
  • Increase in function
  • Decrease in disability
  • Methods: Methods of treatment vary according to an individual's needs.
Treatment methods for patients include:

Joint management programs

  • Lifestyle changes - education of patients and family members, weight loss, diet instruction, energy management tips and joint preservation techniques can all be effective and useful management tools.
  • Physical therapy - with emphasis on maintaining the patients joint motion, muscle strength, and ambulation
  • Occupational therapy - to assist patients in maintaining independence and self reliance in performing activities of daily living.
  • Many times a physical and occupational therapist will work together with the patient to not only supply the necessary instructions needed, but also the equipment and ideas to simplify tasks for patients.
Pharmacological (Drug Treatment)
  • Because osteoarthritis is a degenerative process and not an inflammatory one, pharmacological treatment can be managed in several ways.
  • Acetaminophen (Tylenol) - initially, this may be the drug of choice and clearly has a lower incidence of side effects than other agents which may be used.
  • Aspirin or NSAIDS (non-steroidal anti-inflammatory medications) are frequently used if patients do not respond to Tylenol. Gastrointestinal complications are more likely to occur in this group, with this risk being increased threefold in patients treated with these medications.
  • Pain medications such as darvon, codeine, or in some cases other narcotic agents, can be helpful in short term management of acute flares.
  • Intra-articular injections - not usually recommended in early treatment, joint injections may be helpful to elderly patients or patients in which other medications are ineffective or unsafe to use.
Nutritional supplements
  • There are many over-the-counter nutritional supplements that claim they can improve the symptoms of arthritis. These supplements should be discussed with your physician. Many of these supplements have not been scientifically studied or proven to be of benefit to the patient.
  • Recently, much interest has been generated in the use of glucosamine, chondroitin sulfate, or the combination. Laboratory and clinical studies have suggested that these materials, which are the building blocks for cartilage, may have a positive effect on cartilage and arthritis. One nutritional supplement, Cosamin DS, is a patented combination of these two materials. In a small clinical study, this combination was shown to improve the pain and function in patients with mild to moderate osteoarthritis. We are currently involved in a larger study to evaluate this further.
Electrical Stimulation Therapy
  • Several studies that we have participated in have evaluated the application of electrical stimulation to the treatment of patients with osteoarthritis and rheumatoid arthritis of the knee and hand. The latest study indicated that treatment with Bionicare® Electrostimulation was effective in delaying the need for prosthetic reconstruction in patients with severe OA of the knee. As this treatment becomes available, it may be a useful method for certain types of arthritis.

Other treatments:

  • Heat/Cold therapy
  • Ultrasound
Surgery - Various surgeries may be beneficial to patients with osteoarthritis, especially when the joints of the lower extremities, or weight bearing joints, are involved. Surgeries which can be performed are:
  • Arthroscopic debridement
  • Cartilage resurfacing
  • Hemi arthroplasty
  • Osteotomy of the hip or knee
  • Total hip replacement
  • Total knee replacement
  • Synovectomy

References
  1. Lorig, K., Fries, P.H., James, F., The Arthritis Helpbook, 4th ed., Addison-Wesley Publishing Co., 1995.
  2. Brunton, S., Clinical Evaluation of the Patient with Osteoarthritis, Postgraduate Medicine Special Report, McGraw-Hill Healthcare Information Programs, August 1998.
  3. Hochberg, M.C., Altman, R.D., Brandt, K.D., et al., Guidelines for the Medical Management of Osteoarthritis, Arthritis Rheum., 38 (II): 1535-1546, 1995.
  4. Altman, R., Alarcon, G., Appelrouth, D., et al., The American College of Rheumatology Criteria for the Classification and Reporting of Osteoarthritis of the Hip, Arthritis Rheum., 34 (5): 505-514, 1991.
  5. Altman, R., Asch, E., Block, D., et al., Development of Criteria for the Classification of Osteoarthritis of the Knee, Arthritis Rheum., 29 (8): 1039-1049, 1986.
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