The Journal of Musculoskeletal
Medicine. Vol. 28 No. 10
Current Approaches to Pain
Management for Patients With Osteoarthritis
Principles of care and an evidence
basis have provided effective treatment
By ANNE QUISMORIO, MD, MPH
SHUNTARO SHINADA, MD
RICHARD S. PANUSH, MD | October 9, 2011
SHUNTARO SHINADA, MD
RICHARD S. PANUSH, MD | October 9, 2011
Dr Quismorio is a postdoctoral
fellow, Dr Shinada is assistant professor, and Dr Panush is professor, division
of rheumatology, department of medicine, in the Keck School of Medicine at the
University of Southern California and the USC+LAC Medical Center in Los
Angeles.
ABSTRACT: By using a principle- and
evidence-based approach to treatment of patients with osteoarthritis (OA) pain,
physicians can improve patients’ function and comfort and reduce their pain and
disability. The principles of care include confirming the diagnosis, seeking
preventable or reversible underlying or primary disease, identifying the site
or sites of OA, and using reasonable clinical judgment in assessing patients.
Begin therapy with patient education, explanation, discussion of prognosis, and
nonpharmacological modalities. Pharmacological therapy begins with
acetaminophen. Whenever possible, manage monarticular or oligoarticular disease
with topical or local therapies, avoiding unnecessary systemic medications.
Primary OA affects a typical distribution of joints; OA of other joints should
alert the physician to a possible secondary OA. Most patients can be helped. (J Musculoskel Med. 2011;28:391-396)
_______________________________________________________________________________________________
"Doctor, I'm so relieved to see
you," the patient said. "The nurse practitioner told me I have
osteoarthritis (OA) all over. I hurt terribly. I tried Tylenol and Advil, but
they didn't help. Some of my friends with similar problems have told me they
had newer treatments, like Lyrica, Neurontin, Cymbalta, Ultram, and Savella, as
well as herbal medications, ginger, massage, fish oils, yoga, electromagnetic
field therapy, spas, glucosamine(Drug information on glucosamine), chrondroitin, acupuncture, tidal
irrigation, marijuana, patches, ointments, Duragesic, joint injections, and
operations—after they had extensive MRI and other testing—and swear by the
results. I'm confused and don't know what to do. Please help! I'm so
desperate!"
Treatment of patients with OA pain
can be challenging but is rewarding, because they can be helped, sometimes
dramatically. By using a principle- and evidence-based approach, physicians can
improve patients' function and comfort and reduce their pain and disability.
Their lives are restored, at least in part, and that is enormously satisfying.
By clinical definition, OA includes
painful symptoms. Therefore, all approaches to management—from the simplest to
the most aggressive—are designed to benefit patients. Used properly, they are
inextricably linked and are part of an effective therapeutic regimen.
This principle- and evidence-based
approach has been effective for most patients, providing comfort, reducing disability,
and improving quality of life. The occasional patients who do not respond
reasonably well to such a comprehensive therapeutic regimen may benefit from
referral to more expert consultants.
In this article, we describe the
principles of caring for patients with painful OA. We discuss approaches to
patients with "pain all over" and approaches to pain management in
specific joints.
TABLE 1
Principles of managing OA
Principles of managing OA
Goals of therapy include the
restoration and preservation of patients' physical independence by providing
symptomatic relief and maintaining quality of life and function. The ultimate
goals are to halt disease progression (have “disease-modifying” therapy for
OA), reverse established disease, achieve “cures,” and prevent disease.
However, the current therapies, although usually helpful, are only palliative.
Thus, the basic principles for managing OA pain (Table 1) are as follows:
• Confirm the diagnosis. Do
not miss calcium pyrophosphate dihydrate crystal deposition disease,
inflammatory arthritis, erosive/inflammatory OA, polymyalgia rheumatica (PMR),
fibromyalgia syndrome (FMS) (alone or superimposed), associated depression,
neurological or vascular disease, endocrinological disease (thyroid or
parathyroid), chronic pain syndromes (eg, complex regional pain syndrome),
tendinitis/bursitis (do not confuse epicondylitis with elbow disease, de
Quervain tenosynovitis with wrist arthritis, anserine bursitis with knee
arthritis, or trochanteric bursitis with hip disease), ochronosis, or
hemochromatosis. When in doubt, obtain expert consultation.
• Seek preventable or
reversible underlying or primary disease.
FIGURE
The basic principles for managing osteoarthritis (OA) pain include identifying the disease site or sites. Disease may be "generalized" but often is localized to specific joints. As in other joints, local heat, physical measures, and topical therapies may be beneficial for knee OA.
The basic principles for managing osteoarthritis (OA) pain include identifying the disease site or sites. Disease may be "generalized" but often is localized to specific joints. As in other joints, local heat, physical measures, and topical therapies may be beneficial for knee OA.
• Identify the site or sites
of OA. Disease may be “generalized” but often is localized to specific joints,
such as the distal interphalangeal (DIP), first metacarpophalangeal (MCP),
first carpometacarpophalangeal (CMC), axial skeleton, hip, knee (Figure), and first metatarsophalangeal
(MTP) joints.
• Use reasonable clinical
judgment in assessing patients. Experienced clinicians usually recognize OA
readily without obtaining extensive diagnostic studies. Plain x-ray films
usually are sufficient to identify anatomical abnormalities. Serological
studies usually are not necessary, and they may simply introduce
confusion—rheumatoid arthritis, systemic lupus erythematosus, and other
rheumatologic disorders may be excluded with a thoughtful, thorough, informed
clinical evaluation without laboratory testing.
• Begin therapy with patient
education, explanation, discussion of prognosis, and nonpharmacological
modalities. Many patients feel relieved to learn that their disease is not
necessarily rapidly progressive or destructive. Patients can benefit from
various nonpharmacological strategies.
Because obesity is a risk factor for
the development and progression of OA, patients should be counseled on weight
loss. Exercise programs should be tailored to individual patients.
Attention to footwear, gait, and
ambulation may result in symptomatic improvement. Patients should be educated
about the proper use of walking aids because they may help reduce hip and knee
OA pain.
Useful adjuncts to management
include help with activities of daily living, activity modification, quadriceps
strengthening exercises, patellar taping, and formal programs of occupational
and physical therapy. Some patients cope better and some symptoms may be
minimized with cognitive-behavioral therapy or formal counseling.
• Pharmacological therapy, if
needed, begins with acetaminophen (up to 4 g/d). NSAIDs also are beneficial but
should be used at the lowest effective dose. The advantage of acetaminophen
over NSAIDs is its safety profile. Because NSAIDs have been associated with GI
and renal adverse effects, they should be used with caution in patients who
have underlying cardiovascular, renal, or GI disease. The response to a
specific NSAID differs from one patient to another.
Cyclooxygenase (COX)-2 inhibitors,
such as celecoxib(Drug information on celecoxib), may be preferable for patients who
have a history of GI ulcers, are receiving anticoagulation therapy, or have a
bleeding diathesis. NSAIDs may be added as clinically indicated for younger
patients and perhaps patients who do not have comorbid medical problems, are
also taking corticosteroids or anticoagulants, and did not have previous ulcer
disease or GI bleeding. To prevent GI adverse effects, a COX-2 selective
inhibitor or a nonselective NSAID together with misoprostol(Drug information on misoprostol) or a proton pump inhibitor may be
prescribed. We also might prescribe a nonacetylated salicylate (disalicylate,
choline magnesium trisalicylate).
For persistently symptomatic joints
for which injections are feasible, intra-articular corticosteroids or
hyaluronan may be considered. If there is persistent pain, tramadol(Drug information on tramadol) also should be considered. This
regimen should provide satisfactory symptomatic relief for most patients with
OA. Additional pharmacological treatments include some topical medications
(capsaicin cream and diclofenac(Drug information on diclofenac) patch or ointment) that also may be
quite useful for specific painful or tender areas.
• Whenever possible, manage
monarticular or oligoarticular disease with topical or local therapies or both,
avoiding unnecessary systemic medications.
• Other approaches to
treatment that have been suggested to provide benefit include acupuncture, pregabalin(Drug information on pregabalin), gabapentin(Drug information on gabapentin), milnacipran, and duloxetine(Drug information on duloxetine). Many clinicians now consider
glucosamine and chondroitin to have no important clinical value, but they are
generally safe and well-tolerated and some patients do report benefit. In our
opinion, there is insufficient evidence to support nonexperimental use of tidal
lavage, platelet-rich plasma therapy, or herbal and other complementary and
alternative medicines for patients with OA.
• We do not recommend routine
or long-term use of narcotic analgesics for managing patients with OA. Although
these medications are effective for pain management, they should be used rarely
and only in patients who are refractory to other pharmacological treatments. Narcotic
analgesics should be prescribed by physicians who are experienced in caring for
persons receiving these agents.
• Some surgical procedures for
appropriate joints in select patients can result in dramatic benefit.
How to approach patients with
"pain all over"?
OA should not cause diffuse,
nonlocalized pain; patients who complain of this should be assessed for other
or associated conditions. For patients with OA, the symptoms should be
correlated with disease in specified joints.
For example, widespread pain may
reflect FMS; PMR; other arthopathies or rheumatologic disease; endocrinological
or metabolic disorders; neuropathy; vascular disease; central sensitization
syndrome; or OA of the shoulders, knees, hips, or axial skeleton, and there
also might be bursitis or tendinitis. A careful evaluation can clarify this.
When sites with OA are identified and specific symptoms are related to them,
rational and individualized therapeutic approaches can be developed that are
most likely to be successful, and the ordering of expensive and extensive
imaging studies and then prescribing something such as Tylenol #3 can be
avoided.
OA can affect multiple joints,
especially the DIP joints, proximal interphalangeal (PIP) joints, CMC joints,
MTP joints, cervical and lumbar spine facet joints, knees, and hips. Many
patients who have OA of the DIP or PIP joints may have physical abnormalities
that are asymptomatic. A few patients may have “inflammatory” OA, usually of
the hands, with an elevated erythrocyte sedimentation rate or C-reactive
protein level. They may benefit from hydroxychloroquine(Drug information on
hydroxychloroquine)
or NSAIDs.
How to approach patients with
localized or oligoarticular OA?
These patients may be treated
initially with nonmedicinal approaches, such as physical therapy and local heat
therapy. They also may derive benefit from topical therapies, alternatives to
oral NSAIDs that include diclofenac gel and diclofenac patch. Lidocaine(Drug information on lidocaine) patches and topical menthol(Drug information on menthol)- and capsaicin-based creams also
may provide relief, albeit temporary.
TABLE 2
Approaches to managing OA
Approaches to managing OA
Local injection with corticosteroids
may be used for patients who have severe pain in 1 or 2 joints. The goal is to
provide short-term, temporary relief of OA pain; this usually does not provide
long-lasting, permanent relief. Injection of hyaluronic acid into affected
joints also may be beneficial for select patients. Patients who do not respond
to these may benefit from systemic medical therapies. Acetaminophen may provide
symptomatic relief for patients who have OA pain (Table 2).
Primary OA affects a typical
distribution of joints, such as the cervical spine or lumbar spine. OA of other
joints should alert the physician to a possible secondary OA.
Hands/wrists. Although PIP and DIP OA can be
unsightly, it usually is asymptomatic and may not cause discomfort, pain, or
disability. Conservative therapy with local heat or paraffin(Drug information on paraffin) baths or topical therapies may
provide pain relief. Local corticosteroid injections can reduce pain but may be
difficult without ultrasonographic guidance to ensure proper localization.
Seldom would a patient require joint fusion surgery for severe pain at the PIP
or DIP joints. Acetaminophen or NSAID therapy or both may also provide
temporary relief, especially when the joints are symptomatic.
The first CMC joint may be
problematic because it is used in grasping and pinching and for almost every
activity that involves the hand. Patients often lose strength in their fingers
and may need assistive devices to complete their activities of daily living. A custom
splint worn at nighttime can ease the pain. Local corticosteroid injections
usually are of limited benefit. The potential for surgical intervention is
limited by the need to use this joint in everyday life.
Shoulders. Primary OA of the shoulder does not occur often.
Degenerative changes of the glenohumeral joint should prompt the physician to
consider that OA may be the result of another cause (eg, trauma, previous
infection, neuropathy or radiculopathy, crystal deposition disease). If
corticosteroid injections are ineffective or contraindicated, hyaluronic acid
injections may be beneficial for glenohumeral joint arthritis. Ultrasonographic
guidance is recommended.
Hips. OA of the hip causes pain and disability for many
patients. Corticosteroid and hyaluronic acid injections may be of benefit. When
conservative, physical, systemic, and injection therapies are ineffective,
surgical intervention with total hip arthroplasty should be considered.
Knees. Knee OA is a common problem. As in other joints, local
heat, physical measures, and topical therapies may be beneficial.
We recommend quadriceps
strengthening and range of motion exercises, although their value has been
questioned. Glucosamine may be only slightly beneficial to patients who have
mild knee OA. Corticosteroid and hyaluronic acid injections may provide
temporary relief for patients who have contraindications to surgical
intervention.
Attention to lower extremity
biomechanics is important. Some patients are helped by assisted ambulation,
orthoses, and braces. Surgery is indicated when pain becomes severe and
diminished function and quality of life become unacceptable to the patient.
Radiographic changes associated with knee OA usually are not good indicators
for the necessity of surgery; however, when these changes are associated with
refractory pain disability, surgical intervention should be considered. Total
knee arthroplasty usually is preferable to arthroscopic and partial knee
arthroplasties for knee OA.
Feet. OA of the feet usually involves the first MTP joint and
presents as a bunion or hallux valgus. This condition can be exacerbated in
patients who wear narrow or high-heeled shoes. Wide-fitting shoes or orthoses
help reduce the valgus deformity, which may reduce pain. Surgery is indicated
when recommended therapeutic measures prove to be ineffective.
Neck/back. The principles of care outlined above apply to OA of the
axial skeleton. See the “Bibliography” for more information.
We counsel patients with OA to have
reasonable expectations, and we express confidence that we have therapies that
will improve their lives. For patients who have one or a few joints involved,
we try largely physical, topical, and injection therapies, sparing them
systemic medications. For those who are still symptomatic or have
multiple-joint involvement, we include systemic therapy. Most patients can be
helped. A few may need referral for more expert consultation.
Bibliography
• Altman RD, Hochberg MC, Moskowitz RW, Schnitzer TJ. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines: Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee. American College of Rheumatology. Atlanta. 2000. http://www.rheumatology.org/practice/clinical/guidelines/oa-mgmt.asp. Accessed September 8, 2011.
• Anandacoomarasamy A, March L. Current evidence for osteoarthritis treatments. Ther Adv Musculoskeletal Dis. 2010;2:17-28.
• Bhangle S, Sen D, Mihailescu V, et al. Potential new therapies for osteoarthritis: a critical assessment. J Musculoskel Med. 2008;25(suppl):S15-S23.
• Bhangle S, Sapru S, Panush RS. Back pain made simple: an approach based on principles and evidence. Cleve Clin J Med. 2009;76:393-399.
• Bijlsma JW, Berenbaum F, Lafeber FP. Osteoarthritis: an update with relevance for clinical practice. Lancet. 2011;377:2115-2126.
• Bryant LR, des Rosier KF, Carpenter MT. Hydroxychloroquine in the treatment of erosive osteoarthritis. J Rheumatol. 1995;22:1527-1531.
• Jordan KM, Arden NK, Doherty M, et al; Standing Committee for International Clinical Studies Including Therapeutic Trials ESCISIT. EULAR recommendations 2003; an evidence based approach to the management of knee osteoarthritis: report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. 2003;62:1145-1155.
• Mandl L. Treating the pain of osteoarthritis—where do we go from here? J Rheumatol. 2011;38:1535-1537.
• Mease PJ, Hanna S, Frakes EP, Altman RD. Pain mechanisms in osteoarthritis: understanding the role of central pain and current approaches to its treatment. J Rheumatol. 2011;38:1546-1551.
• Punzi L, Bertazzolo N, Pianon M, et al. Soluble interleukin 2 receptors and treatment with hydroxychloroquine in erosive osteoarthritis. J Rheumatol. 1996;23:1477-1478.
• Schnitzer TJ. Update on guidelines for the treatment of chronic musculoskeletal pain. Clin Rheumatol. 2006;25(suppl 1):S22-S29.
• Sullivan MD, Bentley S, Fan MY, Gardner G. A single-blind, placebo run-in study of duloxetine for activity-limiting osteoarthritis pain. J Pain. 2009;10:208-213.
• Vista ES, Lau CS. What about supplements for osteoarthritis? A critical and evidenced-based review. Int J Rheum Dis. 2011;14:152-158.
• Zhang W, Doherty M, Arden N, et al; EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). EULAR evidence based recommendations for the management of hip osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2005;64:669-681.
• Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007;66:377-388.
• Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-162.
• Altman RD, Hochberg MC, Moskowitz RW, Schnitzer TJ. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines: Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee. American College of Rheumatology. Atlanta. 2000. http://www.rheumatology.org/practice/clinical/guidelines/oa-mgmt.asp. Accessed September 8, 2011.
• Anandacoomarasamy A, March L. Current evidence for osteoarthritis treatments. Ther Adv Musculoskeletal Dis. 2010;2:17-28.
• Bhangle S, Sen D, Mihailescu V, et al. Potential new therapies for osteoarthritis: a critical assessment. J Musculoskel Med. 2008;25(suppl):S15-S23.
• Bhangle S, Sapru S, Panush RS. Back pain made simple: an approach based on principles and evidence. Cleve Clin J Med. 2009;76:393-399.
• Bijlsma JW, Berenbaum F, Lafeber FP. Osteoarthritis: an update with relevance for clinical practice. Lancet. 2011;377:2115-2126.
• Bryant LR, des Rosier KF, Carpenter MT. Hydroxychloroquine in the treatment of erosive osteoarthritis. J Rheumatol. 1995;22:1527-1531.
• Jordan KM, Arden NK, Doherty M, et al; Standing Committee for International Clinical Studies Including Therapeutic Trials ESCISIT. EULAR recommendations 2003; an evidence based approach to the management of knee osteoarthritis: report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. 2003;62:1145-1155.
• Mandl L. Treating the pain of osteoarthritis—where do we go from here? J Rheumatol. 2011;38:1535-1537.
• Mease PJ, Hanna S, Frakes EP, Altman RD. Pain mechanisms in osteoarthritis: understanding the role of central pain and current approaches to its treatment. J Rheumatol. 2011;38:1546-1551.
• Punzi L, Bertazzolo N, Pianon M, et al. Soluble interleukin 2 receptors and treatment with hydroxychloroquine in erosive osteoarthritis. J Rheumatol. 1996;23:1477-1478.
• Schnitzer TJ. Update on guidelines for the treatment of chronic musculoskeletal pain. Clin Rheumatol. 2006;25(suppl 1):S22-S29.
• Sullivan MD, Bentley S, Fan MY, Gardner G. A single-blind, placebo run-in study of duloxetine for activity-limiting osteoarthritis pain. J Pain. 2009;10:208-213.
• Vista ES, Lau CS. What about supplements for osteoarthritis? A critical and evidenced-based review. Int J Rheum Dis. 2011;14:152-158.
• Zhang W, Doherty M, Arden N, et al; EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). EULAR evidence based recommendations for the management of hip osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2005;64:669-681.
• Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007;66:377-388.
• Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-162.
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