Contrary to popular perception, for the 21 million Americans with osteoarthritis, diagnosis need not signal inevitable deterioration and disability. Instead, the aches, pains, and stiffness that characterize the condition can often be controlled and alleviated. The term conservative management of osteoarthritis describes non-surgical treatments that provide symptomatic relief, modification of the course of the disease, and an approach that allows patients to adjust to the realities and take more control of their condition.
"Early diagnosis is the key to conservative management," explains Edward C. Jones, MD, MA, Assistant Attending Orthopaedic Surgeon at HSS. "The sooner you recognize the presence of arthritis in any joint, the better the patient can understand what's going on, what to expect, and how he or she can make things better."
Arthritis is an umbrella term for a number of disease processes in which the joint surface is injured (either acutely or through gradual wear and tear), the surrounding tissues become inflamed and the cushion of cartilage that lines the ends of the bones (known as articular cartilage) deteriorates. As the cartilage surface wears and thins, a progression of symptoms develop. Eventually, at the end stage of arthritis, the articular cartilage wears away completely and bone on bone contact occurs. The vast majority of people diagnosed have osteoarthritis and in most cases the cause of their condition cannot be identified. One or more joints may be affected. (Rheumatoid arthritis-and other forms of inflammatory arthritis-is a systemic immune disorder that affects multiple joints. In such cases, the body perceives the joint lining (synovium) and cartilage to be foreign substance and attacks it. Far fewer Americans are diagnosed with inflammatory arthritis.)
Anteroposterior radiograph of a normal hip joint. There is a uniformly lucent joint space (arrow).
For reasons that are not clearly understood, osteoarthritis is more common in women than in men. There appears to be a genetic factor in its development, but a diagnosis in one generation does not necessarily predict it's occurrence in the next. Research also suggests that cartilage metabolism plays a role in the disease, with some people being better able to withstand injury and wear and tear to the cartilage, than others.
Regardless of which joint is affected, osteoarthritis takes a common course. The pain and stiffness that develop result from the loss of smooth, gliding cartilage on the joint surfaces. As the cartilage thins and becomes uneven, stiffness and catching occur. Motion is diminished and the surrounding joint lining, ligaments and tendons contract and tighten. The joint becomes painful to move, and there is often a progressive weakening of the muscles that control it. The practical implications of these limitations are disruption in work and recreation. Patients may become discouraged and demoralized. A loss of vigor can interfere with personal relationships and intimacy.
Anteroposterior radiograph of a hip with osteoarthritis. There is asymmetric superolateral joint space narrowing. Sclerosis and subchondral cyst in the adjacent bone are seen (arrow).
Taking Control of Osteoarthritis
It is important to understand that two joints that show the same cartilage loss on x-ray may behave very differently in terms of discomfort and limited function. The weak, stiff joint will be more painful and disabling than a joint with preserved strength and motion. And of course, additional factors such as body weight, other joint involvement and general health are also very important in determining the level of disability and quality of life. Patients who embark on a conservative course of treatment for arthritis are taking control of their condition and seeking the best possible outcome.
Certainly the place to begin is cultivating good general health, including cardiovascular conditioning. Dr. Jones also places a strong emphasis on maintaining a healthy body weight. "This is particularly important in individuals with arthritis of the hip, knee and low back, in whom excess pounds place a tremendous strain on the joint."
Maintaining range of motion
Stretching and strengthening exercises help maintain range of motion and alleviate stiffness. It's important to note, however, that guidance from an orthopaedic surgeon, specialist in sports medicine, a physiatrist, or physical therapist is needed. The wrong exercises can place undue stress on the joint and exacerbate the condition.
Recovering and maintaining range of motion of arthritic joints is very important. This is particularly true with arthritis of the shoulder, low back, hip and knee. Once motion is lost through contracture of surrounding soft tissues it is very difficult to regain, but with early stretching severe stiffness can be avoided and progressive motion loss minimized.
In addition to making the patient feel better, the right kind of supervised stretching yields important mechanical benefits. For example, minimizing hip or knee stiffness protects the low back from undue strain. Another benefit of stretching is preserving load distribution on the joint surface. In a healthy person with supple joints, the weight that is borne by a joint is distributed over a broad surface. If the joint becomes stiff, and motion is limited, the weight is concentrated on a small portion of that joint surface. The increased load on that one area will rapidly wear out the cushion of articular cartilage. By maintaining range of motion, the patient is able to distribute the weight over a larger area, thereby slowing that "wearing out" process.
Exercise should be considered with three specific goals: strengthening the muscles that control the arthritic joint, exercises that fortify adjacent joints (such as the low back) and exercise that improves overall fitness.
The benefits of strengthening muscles that control an arthritic joint, such as the shoulder, hip or knee have been well documented. For example, with hip arthritis, strong abductor muscles (muscles that lift the leg away from the midline) can reduce the load experienced by the joint surface and minimize limp. The limp associated with hip arthritis may be due to pain and stiffness, but in most cases weak abductor muscles are the major reason for limping (don't forget, expert guidance is essential to learn to do abductor muscle strengthening exercise properly). For the knee, increased power in the quadriceps muscles in the front of the thigh dramatically improves knee function, such as climbing stairs and getting up from a chair. Strengthening exercises benefit the patient because better-conditioned muscles are able to power the joint through a range of motion and bear more of the load around the joint, thereby redistributing it from the cartilage surfaces.
In addition to focusing on the affected joint, Dr. Jones advises patients with hip or knee arthritis to do exercises that help stretch and strengthen the lower back. Muscle spasm and ultimately arthritis in the lower back may develop independently or as the result of strain on the lower back due to limping or restricted hip or knee motion. An exercise program may alleviate or even prevent low back symptoms.
Dr. Jones also points out that "Any kind of exercise that is sustained for 20 minutes or more will cause the release of endorphins, which add to the patient's comfort and feeling of well-being."
Patients who have been athletic all their lives and enjoy recreational sports may find that a diagnosis of osteoarthritis requires them to alter their exercise and sports routine in order to protect their joints. While this can initially pose a psychological challenge to some patients, many are often pleasantly surprised to find that the adjustment is not as difficult as they have foreseen. A jogger may switch to bike riding and continue to receive the same aerobic benefit. Individuals who are not able to bicycle or walk on a treadmill may find that swimming or aqua jogging (performed in the deep end of a pool using a flotation device) offers them an enjoyable alternative for deriving the same strengthening and cardiovascular benefit. An aqua jogger who simulates walking, running or cross country skiing against the fluid resistance of water in a pool can maintain overall fitness and cardiovascular health while strengthening the upper and lower body and preserving the good mechanics of proper gait and bearing - form does indeed follow function.
"The important thing is to identify an appropriate form of exercise that the patient will enjoy, be motivated to continue, and can practically fit into their schedule at least three times a week," says Dr. Jones. For individuals who have not been exercising on a regular basis, getting started is the hurdle. Dr. Jones generally urges a trial effort. "After exercising for two to four weeks, patients often find that the benefits are so gratifying that they are motivated to continue."
Canes, Shoes and Chairs
Although many people resist the idea-associating it with age and disability-use of a cane or some type of walking stick can be very helpful for individuals with arthritis of the hip. During normal walking, due to muscle contraction around the joint added to the direct load, the hip bears two to three times the weight of the body. Use of a cane on the opposite side of the affected joint, diminishes the load on the hip by one-half. Dr. Jones advises patients to use the cane selectively, when they know they will be walking some distance, as in a fairground or shopping mall. Doing so can alleviate flare-ups of discomfort both during and after the activity. People with arthritis of the hip, knee and back can also benefit from wearing shoes with a cushioned heel and sole that decrease the impact of walking. Also, high chairs are much more comfortable for anyone with back, hip or knee arthritis.
Alleviating Night Pain
In some cases night pain caused by arthritis, predominantly in the hip or shoulder, may be very difficult to endure and a sign that it is time to consider surgery. However, there are some measures that can offer relief. Use of a firm conforming mattress that distributes weight over the entire body can minimize pressure on the affected joint. Pillows between the knees or under the arm may also help. With knee arthritis, a pillow under the entire leg may help by elevating the leg, but sleeping with a pillow under the knee that results in a bent knee through the night should be avoided as it will lead to a flexion contracture (loss of full extension of the knee). Patients can try a variety of sleep positions as well.
Use of Heat and Cold
If a joint is irritated, application of heat and cold can offer pain relief, and some general rules apply. If the discomfort is not related to specific activity, application of moist heat may be most effective since it is more penetrating than dry heat and more likely to promote circulation and relieve muscle spasms. If the joint pain is exercise or sports-related, application of ice immediately after the activity may be more effective. Individuals with arthritis may have variable results and may wish to experiment on their own for the most effective temperature.
A number of medications are available for the treatment of arthritis including anti-inflammatory agents, such as aspirin, and the NSAIDs (non-steroidal anti-inflammatory drugs.) Although some of the older NSAIDs carried the risk of causing stomach irritation and affecting blood platelets, a new generation of drugs called Cox-2 inhibitors appears to be both more effective and have fewer side effects. Patients may also be given drugs that address pain only, but because many of the agents in this category are narcotics that can cause dependence, their use tends to be limited and overseen by pain management specialists.
Some orthopaedic surgeons may also use steroid injection or visco-supplementation as part of a treatment plan. Steroids are powerful anti-inflammatory drugs that may offer more and/or longer-lasting relief than oral agents alone. However, because of side-effects associated with these injectable medications, most orthopaedic surgeons make some effort to limit their use. Viscosupplements are viscous substances that are injected into the joint to lubricate the joint and ease movement. The efficacy of both these treatments varies among patients.
So-called alternative medicines or "nutraceuticals", such as glucosamine and chondroitin sulfate, are also available. The purported effect of these supplements is to enhance cartilage metabolism, minimize progressive degeneration and possibly promote cartilage regeneration. However, because these substances are not regulated by the FDA, and because there is insufficient clinical data to demonstrate their efficacy, it is difficult to assess their true value at this time.
A multitude of resources are available to patients with arthritis from books, support groups, and on-line education (such as HSS.edu). Dr. Jones advises patients to be as knowledgeable as possible, to seek out well-researched data, and to maintain a dialog with their orthopaedist or rheumatologist about changes in their condition.
Patients with osteoarthritis should also realize that if, despite their best efforts, conservative management does not provide sufficient relief, joint replacement or arthroplasty represents a highly effective and relatively safe surgical treatment option. The success and durability of prosthetic joints is generally excellent and orthopaedic surgeons continue to refine the materials and techniques used to minimize the trauma of surgery, speed recovery, and improve implant durability.
Regardless of the combination of measures the patient finds most helpful, Dr. Jones stresses the benefits of initiating treatment right at the point of diagnosis. "I can't emphasize enough the importance of being pro-active. I think patients can help themselves in many ways to experience less pain, less disability, less rapid progression, and an enhanced sense of well-being." For patients who do eventually undergo surgery, good physical conditioning and an understanding of the process will speed their recovery and, what's more, improve their final outcome.
While the benefits of conservative treatment of arthritis are vital to the individual, this approach also carries broader social, economic and public health implications. People who suffer from osteoarthritis that is not treated early, miss more work days, require more care from family members or others, and are likely to eventually require more costly treatment. As the population as a whole ages, the incidence of osteoarthritis in the United States is also expected to increase, from today's 21 million to as many as 40 million individuals in 2030.
"I believe the future of treatment for arthritis holds great promise," adds Dr. Jones. "To put it in perspective, thirty years ago our best treatment option for many patients with hip or knee arthritis was aspirin and a cane. Today we have a much better understanding of non-surgical techniques to alleviate pain and disability, and successful joint replacement surgery for those whose disease requires it. We are looking at constantly improving outcomes of care, and five to ten years from now the face of treatment may be completely different. We can expect methods to recognize or even anticipate early osteoarthritis and stop it before it progresses. And with advanced arthritis, there may well be genetic or stem cell-based treatment that regenerates articular cartilage and restores a normal joint surface."
• Diagnostic imaging examinations provided by HSS Radiologists Summary Prepared by Nancy Novick