Osteoarthritis

The Osteoarthritis Research Society International (OARSI) defines the condition as:

“Osteoarthritis is a disorder that can affect any moveable joint of the body, for example, knees, hips, and hands. It can show itself as a breakdown of tissues and abnormal changes to cell structures of joints, which can be initiated by injury. As the joint tries to repair, it can lead to other problems.

Osteoarthritis first shows itself as a change to the biological processes within a joint, followed by abnormal changes to the joint, such as the breakdown of cartilage, bone reshaping, bony lumps, joint inflammation, and loss of joint function. This can result in pain, stiffness and loss of movement.

There are certain factors which make some people more vulnerable to developing osteoarthritis, such as genetic factors, other joint disorders (such as rheumatoid arthritis), injury to the joint from accidents or surgery, being overweight or doing heavy physical activity in some sports or a person’s job¹”.

FACT: Osteoarthritis (OA) is more common as you age, however, it can and does affect younger people as well. This is especially so for those who may have suffered a joint injury in the past.

FACT: Improvement in pain and disability can happen over time, particularly for OA of the knees and fingers. It is important to understand the positive, active things you can do to help with the pain associated with OA.

FACT: Symptoms (including pain) are NOT strongly related to the structural joint changes seen on x-rays or scans. This means that relying on information from scans alone can be unhelpful.

MYTH: A common myth is that OA worsens over time, no matter what you do. This is not true. OA is not an inevitable part of ageing. OA is a process of attempted repair: the current science suggests this repair process may limit joint damage and symptoms.

The exact causes of OA are still unclear. There are a number of factors that can contribute to the development of OA including:

• Being overweight or obese
• Having previous joint injury, joint surgery and/or history of overuse of the joint (e.g. jobs involving repetitive lifting of heavy loads, kneeling, squatting, use of the hands)
• Your genetics (e.g. a family history of OA)

Osteoarthritis affects people in different ways and symptoms can vary depending on which joint is affected.

Symptoms often develop slowly over time but can become persistent in later stages of OA, especially pain. You can also experience periods of more severe pain, followed by periods where you experience less pain or are pain-free.

We know from science that factors such as low mood, increased stress, over-activity, illness and/or other health conditions can contribute to pain flares or fluctuations. Many of these factors are modifiable –this means these factors can be managed (by you with the support of your health team) to improve your function and pain.

Symptoms of OA include:

• Joint pain and stiffness that is aggravated by too much or too little movement/exercise/activity.
• Functional limitations made worse by muscle weakness and/or joint instability.
• Reduced quality of life.

Osteoarthritis can be diagnosed from a clinical examination without the need for any special tests or x-rays if a person:²

• Is aged 45 years or older
• Has joint pain related to activity or movement
• Has morning stiffness that lasts for less than 30 minutes.

X-rays, scans or blood tests are only required if the doctor needs to rule out other causes of your joint pain. Importantly, these tests do not show pain, nor are they helpful in determining the best management for you.

Osteoarthritis, as a chronic condition, requires holistic care^2-4. A holistic “whole person” approach to care means both you and your health professionals) working together to design a management plan tailored to your unique needs and preferences. See the right care for OA fact sheet.

If you have osteoarthritis, you may have other chronic conditions, such as cardiovascular disease or diabetes. It is also common to experience depression, anxiety and/or feel socially isolated. When you work with your health professional, it is important your tailored plan addresses all these factors, so you get the best possible outcome. Your management plan should also consider your family, social, and occupational needs.

A management plan that emphasises the simple, safe and low cost options is typically best. There are three core components of best management of OA ^3-5, including:

1. Information and education about OA
   1. Learn about the condition and understand what treatments are the most effective.
2. Physical activity and exercise
   1. Regular activity/exercise helps relieve symptoms and improves function and has multiple positive benefits for other body systems and mood.
3. Weight loss for people who are overweight/obese

For more information about these components of care, download the fact sheet on right care for OA and see the ‘Helpful tips’ section below.

In  addition to the core treatments outlined above, other ‘adjunctive’ treatments that may be helpful for some people, include^3-4:

• Heat (such as heat packs or hot water bottles)
• Cognitive behavioural therapy (strategies to support helpful thinking about pain and your habits when you have pain), particularly in combination with exercise
• A short course of manual therapy (such as joint mobilisation or massage)
• Transcutaneous electrical stimulation (TENS) units (for use at home)
• Assistive devices (such as tap turners, walking sticks and others)
• Some medications (see next section below)

There are some treatments that are NOT recommended for OA, ^3,4 This is because there is either no evidence that they are beneficial, or evidence is that they have only small or no benefits, or because their potential harms may outweigh any benefits. These include:

• Acupuncture,
• Ultrasound therapy,
• Shockwave therapy,
• Laser therapy,
• Cold therapy,
• Orthopaedic footwear, insoles and knee braces,
• Kinesio taping,
• Glucosamine,
• Stem cell therapy,
• Opioid medications,
• Platelet rich plasma (PRP) therapy.

Medications cannot change the underlying OA disease process. Although some medications may assist with pain relief of OA, medicines are not a ‘cure’. Medications provide a ‘therapeutic window’ to allow you to stay active, to stay engaged at work and at home, to exercise regularly and to address weight loss.

Current guidelines recommend that oral and topical (applied to the skin) nonsteroidal anti-inflammatories (NSAIDs) may be helpful. ^3,4 See our medicines and procedures pain management module. Topical NSAIDs may be tried first, and if these are insufficient for pain relief then oral NSAIDs or cyclooxygenase-2 (COX-2) inhibitors may be considered. These oral medications should be used at the lowest effective dose for the shortest period of time due to the risk of gastrointestinal side effects. Whenever oral NSAIDs or COX-2 inhibitors are used, they should be co-prescribed with cover from a medication that helps protect the stomach from side effects (called a proton pump inhibitor).

Although paracetamol (or panadol osteo) has long been considered a standard treatment for OA, the most recent scientific evidence^3,4 suggests that benefits of paracetamol are too small to be of any clinical value. Their use may be associated with infrequent side effects if used at excessive doses, or with long-term regular use. If required, paracetamol should be used, at the lowest effective dose and for the shortest possible time.

For people with moderate to severe OA pain, corticosteroid injections can be considered for short-term relief of pain. Care should be taken with repeated injections due to the potential for harm. There is debate over the role of hyaluronan (Synvisc) injections,^3,4 however Australian guidelines⁴ do not recommend them for hip or knee OA as these are generally not effective, based on current evidence.

Opioid medications, taken either orally or via patches (transdermal) are strongly NOT recommended^3,4 for treatment of OA pain. This is because of the very high risk of dependency and other harmful side effects.

For many people, surgical procedures are not necessary, and may not always be helpful. In some cases, surgical procedures can play an important role in the treatment of OA. People who may benefit from joint surgery include:

• those who experience joint symptoms (pain, stiffness and reduced function) that have a profound impact on quality of life AND;
• those who have tried (and persisted with) the best non-surgical treatments (e.g.; exercise, weight loss) for OA and have not experienced any improvement.

Scientific evidence suggests that these people should be referred to an orthopaedic surgeon (bone doctor) for consideration for joint surgery. The types of surgery that may be useful include joint replacement (arthroplasty), joint fusion (arthrodesis) or joint repositioning (osteotomy).

Arthroscopy is not recommended for knee OA unless a person has a clear history of mechanical knee locking.^2,4Although key hole surgery (arthroscopy) is often thought to be beneficial for knee OA, the most recent scientific evidence suggests that these types of procedures offer little benefit for knee OA and are associated with side effects.⁶

For more information about Osteoarthritis, go to Arthritis Australia, the Australian Rheumatology Association, the WA Elective Joint Replacement Service Model of Care or Cochrane Summaries.

Another reliable, evidence-informed resource for OA is My Joint Pain. You can also find links to Further Assistance.

If you’re experiencing osteoarthritis or are concerned about your osteoarthritis, we recommend our Medical Self-Check.