Pain | December 1, 2015 | Author: The Super Pharmacist
Osteoarthritis (OA) is a clinical condition that causes joints to become painful and stiff. It is the most common cause of arthritis, and one of the most prominent causes of pain and disability worldwide (1). OA most commonly affects the hips, knees, and small joints of the hands, but it can affect any part of the body. Clinically, OA is characterised by the loss of cartilage, remodelled adjacent bones, and associated inflammation around the affected site (2). For patients with OA, many will experience significant pain, a reduced range of joint movement, and, in some cases, bony swelling and deformity. Although most OA is age related, occurring predominantly in patients over the age of 45, it is not an inevitable consequence of getting older and many younger people are also affected by the condition.
There is some evidence to suggest that the chances of initially developing the condition can be reduced through doing regular, gentle exercises and maintaining a healthy diet and weight (3). If patients have developed osteoarthritis, ongoing engagement in exercise and healthy activity is also recommended to help manage the symptoms and severity of the condition. The benefits of regular exercise are twofold for many patients who have OA – regular exercise helps to strengthen muscles around the affected joints, and also helps maintain a good range of joint movement. Exercises such as swimming are ideal for people with OA, although any exercise that does not place an excessive burden on painful joints is better than none. Additionally, regular exercise in conjunction with a healthy diet can also facilitate weight loss, reducing unnecessary burden on the areas and joints most likely to be affected by OA such as the knees, hips and back. A modest weight loss can make a significant difference to the quality of life of many patients.
A large majority of the evidence generally focuses on lower limb OA (hip, knee, ankle and mixed). A systematic review of 60 lower limb trials, undertaken by The Cochrane Collaboration in 2013, covered a total of 12 specific exercise interventions across almost 8500 study participants. Much of the reviewed evidence base consists of Randomised Controlled Trials (RCTs) that compare either specific different exercises or exercise versus no exercise to determine if physical activity plays a role in relieving pain and improving limb function in patients with lower limb OA (4). The results of the large systematic review were conclusively in favour of exercise playing a significant role in alleviating pain, with a number of different combinations:
shown to be significantly more effective than control groups with OA who undertook no exercise at all. In regards to improving joint mobility, the same study also evidenced that combined interventions of flexibility, strengthening and aerobic exercise significantly improved joint function when compared to a control group who undertook no exercise at all. The overwhelming numbers of studies featured in the review were concerned with knee osteoarthritis (44 studies), with hip OA (2 studies) and mixed OA site (12 studies) making up the remainder of the review material. The review concludes that a mixture of exercises that address strengthening, flexibility and increased aerobic capacity are the best combination for the effective management of lower limb OA, helping to reduce the 36 million working days and estimated loss of 1% of GDP that osteoarthritis costs the economy annually (5).
There is a very limited evidence base covering this area of research. In general, paracetamol or topical non-steroidal anti inflammatory drugs (NSAIDs) are considered ahead of oral NSAIDs or opioids. Paracetamol is the recommended first line pharmacologic agent for the treatment of OA in almost every set of international guidelines that are currently available. The topical application of NSAIDS have been evidenced to have the same pain relieving properties as those that are orally administered, although they have significantly less risk of causing gastrointestinal upset and do not come with the additional risks of systemic exposure that accompanies the oral route of administration (6). Topical NSAIDs have been evidenced to be particularly effective for patients with OA in their knees and hands in regards to pain relief and the reduction of swelling (7), and as such a number of different osteoarthritis organisations and healthcare professionals often recommend their use prior to exercise to ensure patients can undertake physical activity with less discomfort (8). However, there is no specific research considering this combination of therapies, despite it regularly being used by many OA patients undertaking exercise.
Many patients with lower limb OA will be given advice on appropriate footwear. Some patients with particularly acute joint pain may also be offered bracing, joint supports, or insoles as a compliment to their pharmaceutical treatment and exercise programme, with the majority of all first line treatment for OA remaining non-pharmaceutical. Diet and the reduction of obesity has also been evidenced to reduce subsequent risk of OA, with a study evaluating 800 patients showing that a reduction in weight of BMI of ≥ 2kg/m2 reduced the risk of future OA development by approximately 50% (9).