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Osteoarthritis

osteoarthritis, osteoarthritis pain treatment
Osteoarthritis OA is a type of joint disease that results from breakdown of joint cartilage and underlying bone5 The most common symptoms are joint pain and stiffness Initially, symptoms may occur only following exercise, but over time may become constant Other symptoms may include joint swelling, decreased range of motion, and when the back is affected weakness or numbness of the arms and legs The most commonly involved joints are those near the ends of the fingers, at the base of the thumb, neck, lower back, knee, and hips Joints on one side of the body are often more affected than those on the other Usually the symptoms come on over years It can affect work and normal daily activities Unlike other types of arthritis, only the joints are typically affected1

Causes include previous joint injury, abnormal joint or limb development, and inherited factors Risk is greater in those who are overweight, have one leg of a different length, and have jobs that result in high levels of joint stress126 Osteoarthritis is believed to be caused by mechanical stress on the joint and low grade inflammatory processes7 It develops as cartilage is lost and the underlying bone becomes affected1 As pain may make it difficult to exercise, muscle loss may occur28 Diagnosis is typically based on signs and symptoms, with medical imaging and other tests occasionally used to either support or rule out other problems In contrast to rheumatoid arthritis, which is primarily an inflammatory condition, in osteoarthritis, the joints do not typically become hot or red1

Treatment includes exercise, efforts to decrease joint stress, support groups, and pain medications13 Efforts to decrease joint stress include resting and the use of a cane Weight loss may help in those who are overweight Pain medications may include paracetamol acetaminophen as well as NSAIDs such as naproxen or ibuprofen1 Long-term opioid use is generally discouraged due to lack of information on benefits as well as risks of addiction and other side effects13 If pain interferes with normal life despite other treatments, joint replacement surgery may help2 An artificial joint typically lasts 10 to 15 years9

Osteoarthritis is the most common form of arthritis affecting about 237 million 33% of the population410 Among those over 60 years old, about 10% of males and 18% of females are affected2 It is the cause of about 2% of years lived with disability10 In Australia, about 19 million people are affected,11 and in the United States, 30 to 525 million people are affected1213 It becomes more common in both sexes as people become older1

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Contents

  • 1 Signs and symptoms
  • 2 Risk factors
    • 21 Primary
      • 211 Work related
    • 22 Secondary
  • 3 Pathophysiology
  • 4 Diagnosis
    • 41 Classification
  • 5 Management
    • 51 Lifestyle changes
    • 52 Physical measures
    • 53 Medication
    • 54 Surgery
    • 55 Alternative medicine
      • 551 Glucosamine and chondroitin
      • 552 Other remedies
      • 553 Acupuncture and other interventions
  • 6 Epidemiology
    • 61 United States
  • 7 History
    • 71 Etymology
  • 8 Research
    • 81 Biomarkers
  • 9 References
  • 10 External links

Signs and symptomsedit

Osteoarthritis most often occurs in the hands at the ends of the fingers and thumbs, neck, lower back, knees, and hips

The main symptom is pain, causing loss of ability and often stiffness "Pain" is generally described as a sharp ache or a burning sensation in the associated muscles and tendons, and is typically made worse by prolonged activity and relieved by rest Stiffness is most common in the morning, and typically lasts less than thirty minutes after beginning daily activities, but may return after periods of inactivity Osteoarthritis can cause a crackling noise called "crepitus" when the affected joint is moved or touched and people may experience muscle spasms and contractions in the tendons Occasionally, the joints may also be filled with fluid14 Some people report increased pain associated with cold temperature, high humidity, and/or a drop in barometric pressure, but studies have had mixed results15

Osteoarthritis commonly affects the hands, feet, spine, and the large weight-bearing joints, such as the hips and knees, although in theory, any joint in the body can be affected As osteoarthritis progresses, movement patterns such as gait, are typically affected16 Osteoarthritis is the most common cause of a joint effusion of the knee17

In smaller joints, such as at the fingers, hard bony enlargements, called Heberden's nodes on the distal interphalangeal joints and/or Bouchard's nodes on the proximal interphalangeal joints, may form, and though they are not necessarily painful, they do limit the movement of the fingers significantly Osteoarthritis of the toes may be a factor causing formation of bunions,18 rendering them red or swollen

Risk factorsedit

Damage from mechanical stress with insufficient self repair by joints is believed to be the primary cause of osteoarthritis19 Sources of this stress may include misalignments of bones caused by congenital or pathogenic causes; mechanical injury; excess body weight; loss of strength in the muscles supporting a joint; and impairment of peripheral nerves, leading to sudden or uncoordinated movements19 However exercise, including running in the absence of injury, has not been found to increase the risk20 Nor has cracking one's knuckles been found to play a role21

Primaryedit

A number of studies have shown that there is a greater prevalence of the disease among siblings and especially identical twins, indicating a hereditary basis22 Although a single factor is not generally sufficient to cause the disease, about half of the variation in susceptibility has been assigned to genetic factors23

As early human ancestors evolved into bipeds, changes occurred in the pelvis, hip joint and spine which increased the risk of osteoarthritis24 Additionally genetic variations that increase the risk were likely not selected against because usually problems only occur after reproductive success25

The development of osteoarthritis is correlated with a history of previous joint injury and with obesity, especially with respect to knees26 Since the correlation with obesity has been observed not only for knees but also for non-weight bearing joints and the loss of body fat is more closely related to symptom relief than the loss of body weight, it has been suggested that there may be a metabolic link to body fat as opposed to just mechanical loading27

Changes in sex hormone levels may play a role in the development of osteoarthritis as it is more prevalent among post-menopausal women than among men of the same age2829 A study of mice found natural female hormones to be protective while injections of the male hormone dihydrotestosterone reduced protection30

Work relatededit

Increased risk of developing knee and hip osteo­arthritis was found in those who:6

    • work with manual handling eg lifting6
    • have physically demanding work6
    • walk at work6
    • have climbing tasks at work eg climb stairs or ladders6

Increased risk of developing hip osteoarthritis over time was found among those those who work in bent or twisted positions6

Increased risk of knee osteoarthritis was found in those who:6

    • work in a kneeling or squatting position6
    • experience heavy lifting in combination with a kneeling or squatting posture6
    • work standing up6

Secondaryedit

lateral front Secondary osteoarthritis due to an old injury with fracture of the ankle in a woman of 82 years old

This type of osteoarthritis is caused by other factors but the resulting pathology is the same as for primary osteoarthritis:

  • Alkaptonuria
  • Congenital disorders of joints
  • Diabetes doubles the risk of having a joint replacement due to osteoarthritis and people with diabetes have joint replacements at a younger age than those without diabetes31
  • Ehlers-Danlos Syndrome
  • Hemochromatosis and Wilson's disease
  • Inflammatory diseases such as Perthes' disease, Lyme disease, and all chronic forms of arthritis eg, costochondritis, gout, and rheumatoid arthritis In gout, uric acid crystals cause the cartilage to degenerate at a faster pace
  • Injury to joints or ligaments such as the ACL, as a result of an accident or orthopedic operations
  • Ligamentous deterioration or instability may be a factor
  • Marfan syndrome
  • Obesity
  • Joint infection

Pathophysiologyedit

Normal hip joint Hip joint with osteoarthritis32

While osteoarthritis is a degenerative joint disease that may cause gross cartilage loss and morphological damage to other joint tissues, more subtle biochemical changes occur in the earliest stages of osteoarthritis progression The water content of healthy cartilage is finely balanced by compressive force driving water out and hydrostatic and osmotic pressure drawing water in3334 Collagen fibres exert the compressive force, whereas the Gibbs–Donnan effect and cartilage proteoglycans create osmotic pressure which tends to draw water in34

However, during onset of osteoarthritis, the collagen matrix becomes more disorganized and there is a decrease in proteoglycan content within cartilage The breakdown of collagen fibers results in a net increase in water content3536373839 This increase occurs because whilst there is an overall loss of proteoglycans and thus a decreased osmotic pull,3640 it is outweighed by a loss of collagen3440 Without the protective effects of the proteoglycans, the collagen fibers of the cartilage can become susceptible to degradation and thus exacerbate the degeneration Inflammation of the synovium joint cavity lining and the surrounding joint capsule can also occur, though often mild compared to the synovial inflammation that occurs in rheumatoid arthritis This can happen as breakdown products from the cartilage are released into the synovial space, and the cells lining the joint attempt to remove themcitation needed

Other structures within the joint can also be affected41 The ligaments within the joint become thickened and fibrotic and the menisci can become damaged and wear away42 Menisci can be completely absent by the time a person undergoes a joint replacement New bone outgrowths, called "spurs" or osteophytes, can form on the margins of the joints, possibly in an attempt to improve the congruence of the articular cartilage surfaces in the absence of the menisci The subchondral bone volume increases and becomes less mineralized hypomineralization43 All these changes can cause problems functioning The pain in an osteoarthritic joint has been related to thickened synovium44 and subchondral bone lesions45

Diagnosisedit

Diagnosis is made with reasonable certainty based on history and clinical examination4647 X-rays may confirm the diagnosis The typical changes seen on X-ray include: joint space narrowing, subchondral sclerosis increased bone formation around the joint, subchondral cyst formation, and osteophytes48 Plain films may not correlate with the findings on physical examination or with the degree of pain49 Usually other imaging techniques are not necessary to clinically diagnose osteoarthritis

In 1990, the American College of Rheumatology, using data from a multi-center study, developed a set of criteria for the diagnosis of hand osteoarthritis based on hard tissue enlargement and swelling of certain joints50 These criteria were found to be 92% sensitive and 98% specific for hand osteoarthritis versus other entities such as rheumatoid arthritis and spondyloarthropathies51

Related pathologies whose names may be confused with osteoarthritis include pseudo-arthrosis This is derived from the Greek roots pseudo-, meaning "false", and arthr-, meaning "joint", together with the ending -osis used for disorders Radiographic diagnosis results in diagnosis of a fracture within a joint, which is not to be confused with osteoarthritis which is a degenerative pathology affecting a high incidence of distal phalangeal joints of female patients A polished ivory-like appearance may also develop on the bones of the affected joints, reflecting a change called eburnation52

Classificationedit

Further information: Radiographic classification of osteoarthritis

A number of classification systems are used for gradation of osteoarthritis:

  • WOMAC scale, taking into account pain, stiffness and functional limitation53
  • Kellgren-Lawrence grading scale for osteoarthritis of the knee It uses only projectional radiography features
  • Tönnis classification for osteoarthritis of the hip joint, also using only projectional radiography features54

Osteoarthritis can be classified into either primary or secondary depending on whether or not there is an identifiable underlying cause

Both primary generalized nodal osteoarthritis and erosive osteoarthritis EOA, also called inflammatory osteoarthritis are sub-sets of primary osteoarthritis EOA is a much less common, and more aggressive inflammatory form of osteoarthritis which often affects the distal interphalangeal joints of the hand and has characteristic articular erosive changes on x-ray55

Osteoarthritis can be classified by the joint affected:

  • Hand:
    • Trapeziometacarpal osteoarthritis
  • Wrist wrist osteoarthritis
  • Vertebral column spondylosis
    • Facet joint arthrosis
  • Hip osteoarthritis
  • Knee osteoarthritis

Managementedit

People with osteoarthritis should do different kinds of exercise for different benefits to the body

Lifestyle modification such as weight loss and exercise and analgesics are the mainstays of treatment Acetaminophen also known as paracetamol is recommended first line with NSAIDs being used as add on therapy only if pain relief is not sufficient56 This is due to the relative greater safety of acetaminophen56

Lifestyle changesedit

For overweight people, weight loss may be an important factor57 Patient education has been shown to be helpful in the self-management of arthritis57 It decreases pain, improves function, reduces stiffness and fatigue, and reduces medical usage57 Patient education can provide on average 20% more pain relief when compared to NSAIDs alone in patients with hip osteoarthritis57

Physical measuresedit

Moderate exercise is beneficial with respect to pain and function in those with osteoarthritis of the knee and hip5859 These exercises should occur at least three times per week60 While some evidence supports certain physical therapies, evidence for a combined program is limited61 There is not enough evidence to determine the effectiveness of massage therapy62 The evidence for manual therapy is inconclusive63 Functional, gait, and balance training have been recommended to address impairments of position sense, balance, and strength in individuals with lower extremity arthritis as these can contribute to a higher rate of falls in older individuals64

Lateral wedge insoles and neutral insoles do not appear to be useful in osteoarthritis of the knee656667 Knee braces may help68 but their usefulness has also been disputed67 For pain management heat can be used to relieve stiffness, and cold can relieve muscle spasms and pain69 Among people with hip and knee osteoarthritis, exercise in water may reduce pain and disability, and increase quality of life in the short term70 Also therapeutic exercise programs such as aerobics and walking reduce pain and improve physical functioning for up to 6 months after the end of the program for people with knee osteoarthritis71

Medicationedit

Treatment recommendations by risk factors
GI risk CVD risk Option
Low Low NSAID, or paracetamol72
Moderate Low Paracetamol, or low dose NSAID with antacid72
Low Moderate Paracetamol, or low dose aspirin with an antacid72
Moderate Moderate Low dose paracetamol, aspirin, and antacid Monitoring for abdominal pain or black stool72

The pain medication acetaminophen is the first line treatment for osteoarthritis5673 However, a 2015 review found acetaminophen to only have a small short-term benefit74 For mild to moderate symptoms effectiveness is similar to non-steroidal anti-inflammatory drugs NSAIDs, though for more severe symptoms NSAIDs may be more effective56 NSAIDs such as naproxen, while more effective in severe cases, are associated with greater side effects, such as gastrointestinal bleeding56 Diclofenac may be the most effective NSAID75

Another class of NSAIDs, COX-2 selective inhibitors such as celecoxib are equally effective when compared to nonselective NSAIDs, and have lower rates of adverse gastrointestinal effects, but higher rates of cardiovascular disease such as myocardial infarction76 They are also more expensive than non-specific NSAIDs77 Benefits and risks vary in individuals and need consideration when making treatment decisions78 NSAIDS applied topically are effective for a small number of people79

Failure to achieve desired pain relief in osteoarthritis after 2 weeks should trigger reassessment of dosage and pain medication80 Opioids by mouth, including both weak opioids such as tramadol and stronger opioids, are also often prescribed Their appropriateness is uncertain, and opioids are often recommended only when first line therapies have failed or are contraindicated8182 This is due to their small benefit and relatively large risk of side effects83 Oral steroids are not recommended in the treatment of osteoarthritis73

There are several NSAIDs available for topical use, including diclofenac A Cochrane review from 2016 concluded that reasonably reliable evidence is available only for use of topical diclofenac and ketoprofen in people aged over 40 years with painful knee arthritis84 Transdermal opioid pain medications are not typically recommended in the treatment of osteoarthritis85 The use of topical capsaicin to treat osteoarthritis is controversial, as some reviews found benefit8687 while others did not88

Joint injection of glucocorticoids such as hydrocortisone leads to short term pain relief that may last between a few weeks and a few months89 Injections of hyaluronic acid have not produced improvement compared to placebo for knee arthritis,9091 but did increase risk of further pain90 In ankle osteoarthritis, evidence is unclear92 The effectiveness of injections of platelet-rich plasma is unclear; there are suggestions that such injections improve function but not pain, and are associated with increased riskvague9394 A 2015 Cochrane review found that intra-articular corticosteroid injections of the knee did not benefit quality of life, had no effect on knee joint space, and clinical effects one to six weeks after injection could not be determined clearly due to poor study quality95

Surgeryedit

If the impact of symptoms of osteoarthritis on quality of life is significant and more conservative management is ineffective, joint replacement surgery or resurfacing may be recommended Evidence supports joint replacement for both knees and hips as it is both clinically effective,9697 and cost-effective9899 Surgery to transfer articular cartilage from a non-weight-bearing area to the damaged area is one possible procedure that has some success, but there are problems getting the transferred cartilage to integrate well with the existing cartilage at the transfer site100

Osteotomy may be useful in people with knee osteoarthritis, but has not been well studied101 Arthroscopic surgery is largely not recommended, as it does not improve outcomes in knee osteoarthritis,102103 and may result in harm104

Alternative medicineedit

Glucosamine and chondroitinedit

The effectiveness of glucosamine is controversial105 Reviews have found it to be equal to106107 or slightly better than placebo108109 A difference may exist between glucosamine sulfate and glucosamine hydrochloride, with glucosamine sulfate showing a benefit and glucosamine hydrochloride not110 The evidence for glucosamine sulfate having an effect on osteoarthritis progression is somewhat unclear and if present likely modest111 The Osteoarthritis Research Society International recommends that glucosamine be discontinued if no effect is observed after six months112 and the National Institute for Health and Care Excellence no longer recommends its use8 Despite the difficulty in determining the efficacy of glucosamine, it remains a viable treatment option113 The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis ESCEO recommends glucosamine sulfate and chondroitin sulfate for knee osteoarthritis114 Its use as a therapy for osteoarthritis is usually safe113115

A 2015 Cochrane review of clinical trials of chondroitin found that most were of low quality, but that there was some evidence of short-term improvement in pain and few side effects; it does not appear to improve or maintain the health of affected joints116

Other remediesedit

Avocado/soybean unsaponifiables ASU is an extract made from avocado oil and soybean oil117 that is sold under many brand names worldwide as a dietary supplement118 and as a drug in France119 A 2014 Cochrane review found that while ASU might help relieve pain in the short term for some people with osteoarthritis, it does not appear to improve or maintain the health of affected joints; the review noted a high quality two year clinical trial comparing to ASU to chondroitin, which has uncertain efficacy in arthritis—the study found no difference between the two117 The review also found that while ASU appears to be safe, it has not been adequately studied to be sure117

Devil's claw,120 Curcumin,121 phytodolor,86 SKI306X12287 and SAMe86123 may be effective in improving pain There is tentative evidence to support cat's claw,124 hyaluronan,125 MSM,86122 and rose hip86 A few high-quality studies of Boswellia serrata show consistent, but small, improvements in pain and function117

There is little evidence supporting benefits for some supplements, including: the Ayurvedic herbal preparations with brand names Articulin F and Eazmov, collagen, Duhuo Jisheng Wan a Chinese herbal preparation, fish liver oil, ginger, the herbal preparation gitadyl, omega-3 fatty acids, the brand-name product Reumalax, stinging nettle, vitamins A, C, and E in combination, vitamin E alone, vitamin K, vitamin D and willow bark There is insufficient evidence to make a recommendation about the safety and efficacy of these treatments86124126

Acupuncture and other interventionsedit

While acupuncture leads to improvements in pain relief, this improvement is small and may be of questionable importance127 Waiting list-controlled trials for peripheral joint osteoarthritis do show clinically relevant benefits, but these may be due to placebo effects128 Acupuncture does not seem to produce long-term benefits129 While electrostimulation techniques such as TENS have been used for twenty years to treat osteoarthritis in the knee, there is no conclusive evidence to show that it reduces pain or disability130

A Cochrane review of low level laser therapy found unclear evidence of benefit131 Another review found short term pain relief for osteoarthritic knees132

Epidemiologyedit

Disability-adjusted life year for osteoarthritis per 100,000 inhabitants in 2004133

Globally as of 2010, approximately 250 million people had osteoarthritis of the knee 36% of the population134135 Hip osteoarthritis affects about 085% of the population134

As of 2004update, osteoarthritis globally causes moderate to severe disability in 434 million people136 Together, knee and hip osteoarthritis had a ranking for disability globally of 11th among 291 disease conditions assessed134

United Statesedit

As of 2012, osteoarthritis affected 525 million people in the United States, approximately 50% of whom were 65 years and older12 It is estimated that 80% of the population have radiographic evidence of osteoarthritis by age 65, although only 60% of those will have symptoms137 The rate of osteoarthritis in the United States is forecast to be 78 million 26% adults by 204012

In the United States, there were approximately 964,000 hospitalizations for osteoarthritis in 2011, a rate of 31 stays per 10,000 population138 With an aggregate cost of $148 billion $15,400 per stay, it was the second-most expensive condition seen in US hospital stays in 2011 By payer, it was the second-most costly condition billed to Medicare and private insurance139140

Historyedit

Evidence for osteoarthritis found in the fossil record is studied by paleopathologists, specialists in ancient disease and injury Osteoarthritis has been reported in fossils of the large carnivorous dinosaur Allosaurus fragilis141

Etymologyedit

Osteoarthritis is derived from the Greek word part osteo-, meaning "of the bone", combined with arthritis: arthr-, meaning "joint", and -itis, the meaning of which has come to be associated with inflammation142 The -itis of osteoarthritis could be considered misleading as inflammation is not a conspicuous feature Some clinicians refer to this condition as osteoarthrosis to signify the lack of inflammatory responsecitation needed

Researchedit

There are ongoing efforts to determine if there are agents that modify outcomes in osteoarthritis Sprifermin is one candidate drug There is also tentative evidence that strontium ranelate may decrease degeneration in osteoarthritis and improve outcomes143144

As well as attempting to find disease-modifying agents for osteoarthritis, there is emerging evidence that a system-based approach is necessary to find the causes of osteoarthritis145 Changes may occur before clinical disease is evident due to abnormalities in biomechanics, biology and/or structure of joints that predispose them to develop clinical disease Research is thus focusing on defining these early pre-osteoarthritis changes using biological, mechanical, and imaging markers of osteoarthritis risk, emphasising multi-disciplinary approaches, and looking into personalized interventions that can reverse osteoarthritis risk in healthy joints before the disease becomes evident

Gene transfer strategies aim to target the disease process rather than the symptoms146

Biomarkersedit

Guidelines outlining requirements for inclusion of soluble biomarkers in osteoarthritis clinical trials were published in 2015,147 but as yet, there are no validated biomarkers for osteoarthritis A 2015 systematic review of biomarkers for osteoarthritis looking for molecules that could be used for risk assessments found 37 different biochemical markers of bone and cartilage turnover in 25 publications148 The strongest evidence was for urinary C-terminal telopeptide of collagen type II uCTX-II as a prognostic marker for knee osteoarthritis progression and serum cartilage oligomeric protein COMP levels as a prognostic marker for incidence of both knee and hip osteoarthritis A review of biomarkers in hip osteoarthritis also found associations with uCTXII149

One problem with using a specific collagen type II biomarker from the breakdown of articular cartilage is that the amount of cartilage is reduced worn away over time with progression of the disease so a patient can eventually have very advanced osteoarthritis with none of this biomarker detectable in their urine Another problem with a systemic biomarker is that a patient can have osteoarthritis in multiple joints at different stages of disease at the same time, so the biomarker source cannot be determined Some other collagen breakdown products in the synovial fluid correlated with each other after acute injuries a known cause of secondary osteoarthritis but did not correlate with the severity of the injury150

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External linksedit

Classification
  • ICD-10: M15-M19, M47
  • ICD-9-CM: 715
  • OMIM: 165720
  • MeSH: D010003
  • DiseasesDB: 9313
External resources
  • MedlinePlus: 000423
  • eMedicine: med/1682 orthoped/427 pmr/93 radio/492
  • Patient UK: Osteoarthritis



  • American College of Rheumatology Factsheet on OA
  • Arthritis Foundation
  • National Institute of Arthritis and Musculoskeletal and Skin Diseases

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    29.10.2014


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