Osteoarthritis – A Closer Look According to the Evidence
According to MSU health plan claims data, osteoarthritis is a very common condition affecting the MSU population. It’s a painful condition for those afflicted and also a costly condition for MSU.
The treatment options for arthritis are many and varied and it can be confusing for a consumer to know which way to turn. When you are in pain, you just want it to stop and it may be tempting to want to try any treatment or cure you hear about. But treatments available may range from effective to actually harmful. So how is a consumer to make a safe and effective choice?
That’s where evidence based medicine comes in. As you consider treatments for any medical condition, ask about the research evidence that supports a recommended course of action. Specifically, what is the strength and quality of the evidence available on various treatments? This allows you to compare the facts and make an educated choice that is most likely to be effective.
Below, courtesy of the Healthy E-Mail initiative at MSU, is information showing what the research says about some of the more common arthritis treatments. In addition, at the end of the article you will find a grading system that tells you about the strength and quality of the evidence used to create the content on arthritis treatments.
Treatment Information for Arthritis
NSAIDs. NSAIDs may be the first thought that comes to mind for treatment arthritis pain. This group of drugs as a whole is very effective at reducing the pain and inflammation associated with osteoarthritis, however there are side effects associated with these medications that individuals should be aware of.
Medications in this class of drugs can cause problems with bleeding from the stomach and intestines (GI bleeding), leading to other medical complications. These medications can also cause problems with the kidneys and blood pressure, especially in older individuals.
For these reasons, this group of medications is generally reserved for short-term treatment of flare ups of pain and stiffness associated with arthritis, not as a regular, daily medication. NSAIDS’s are a more risky treatment method in individuals over age 60 years.
Tylenol® (acetaminophen) has become the medication of choice for the daily treatment of arthritis pain. Acetaminophen is generally a safe medication, doesn’t cause problems with GI bleeding or kidney problems, and provides effective pain control. Researchers compared the effectiveness of acetaminophen with a NSAID medication using an N-of-1 study.
In this study, all participants used each of 3 medications for two weeks. The order of the medications was randomly assigned and included paracetamol (acetaminophen), celecoxib (Celebrex®) or a placebo. Participants rated the effectiveness of each medication after two weeks of use.
The results of the study showed that there was no difference between paracetamol, and celecoxib when rating pain and function; however both medications were better than placebo.
Glucosamine/Chondroiton. This alternative medicine treatment for osteoarthritis has been shown to be effective in protecting joints from further deterioration, especially for arthritis in the knee. Participants in the study were given a daily supplement of either chondroitin or a placebo for two years. X-rays of the knees were taken before and after the study. The results showed that individuals taking the chondroitin had less joint deterioration than those receiving the placebo. However; there was not a difference in pain levels reported by the participants. Good evidence of the benefit of chondritin in other arthritic joints is very limited. The good news is that this treatment has very few side effects.
Antioxidants. Vitamin therapy with antioxidants has very poor supporting evidence, and the currently available studies show no benefit in the use of these vitamins for the treatment of osteoarthritis. Researchers studied the use of vitamin A, C, E and selenium in the management of osteoarthritis. These vitamins may provide benefit in the prevention of other illnesses, however too much of these vitamins could be harmful.
Joint injections with hyaluronic acid. Hyaluronic acid (Synvisc®) is a substance which increases the thickness of the fluid inside of the joint. Research studies on the effectiveness of joint injections with hyaluranic acid showed minimal effectiveness on improvement of pain or function.
Surgery. Arthroscopic surgery is a surgical procedure during which the affected joint surfaces are smoothed, and damaged tissue is removed (this is not referring to joint replacement surgery). This study compared the benefit of physical therapy and medication with arthroscopic surgery.
The physical therapy consisted of one hour per week for three months, and twice daily at home exercises. Medications included acetaminophen; NSAID’s and joint injections with hyaluronic acid. The results of the study showed that surgery was no more effective than good physical therapy and medication. Surgery becomes less effective in individuals over age 50 years.
Leeches anyone? The use of leeches is an old therapy dating back to the 1800’s. Leeches have found a place in modern medical therapy, most commonly after micro vascular surgery, however they have also been used as a treatment for arthritis.
Researchers studied the effectiveness of leech treatments for arthritis of the knee. Participants were enrolled for 6 months in the study and were divided into two treatment groups, one received treatment with leeches the others received a treatment which felt like leeches. Patients receiving leech therapy reported improved function, reduced pain, and less use of medication.
Take Home Message
There are many options for treatment of osteoarthritis; the success depends greatly on the location and severity of the arthritis. Based on quality of evidence it appears that the use of acetaminophen with occasional use of NSAID, in addition to staying physically active, appears to be the most effective; however, a leech treatment every now and again probably won’t hurt!
Editorial Comment
Osteoarthritis is the most common form of arthritis, and it develops as cartilage in your joints wears down over time. Any joint can be affected, however, the most commonly affects joints are your hands, hips, knees and spine. Osteoarthritis gradually worsens with time but can be effectively managed with medication and healthy lifestyle choices including regular physical activity.
Depending on the severity of your arthritis, you may need to work on flexibility, strength, endurance, coordination, and/or balance. This can be accomplished through various types of physical activity.
Stretching exercises can help prevent the stiffness associated with osteoarthritis and help prevent injury.
Strengthening muscles and ligaments helps arthritic joints become stronger and reduces stress on the joint. Stronger thigh muscles, for example, take some of the stress off of weight-bearing joints such as knees and hips. Simple exercise, such as walking, can significantly decrease knee pain.
Mobility. Exercise helps to keep your joints mobile. A regular exercise program is an important part of anyone's lifestyle. If you have osteoarthritis, check with your health care provider before beginning or continuing any exercise so that you can determine whether it is safe and effective for arthritic joints.
Physical Therapy. Working with a physical therapist can help an individual with arthritis learn the best exercise for their particular condition. Physical therapy can also improve mobility (such as walking, going up stairs, or getting in and out of bed), relieve pain, and restore physical function and overall fitness. A physical therapist uses exercise, manual therapy, education, and modalities such as heat, cold, and electrical stimulation to work toward these goals.
Weight loss. if you are overweight, weight reduction can reduce the amount of stress on weight bearing joints, which may help reduce pain .
For more information on Osteoarthritis visit the Healthwise Knowledge base at www.healthwise.msu.edu or visit the Mayo Clinic Web site at http://www.mayoclinic.com/health/osteoarthritis/DS00019
Research Quality Grade: range depending on the reference study 1=A+ through 3=B
Reference and Further Reading
Yelland MJ, Nikles CJ, McNairn N, Del Mar CB, Schluter PJ, Brown RM. Celecoxib compared with sustained-release paracetamol for osteoarthritis: a series of n-of-1 trials. Rheumatology 2007; 46:135-140.
Andereya S, Stanzel S, Maus U, et al. Assessment of leech therapy for knee osteoarthritis: a randomized study. Acta Orthop 2008;79:235-43.
Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2008; 359(11):1097-1107.
Canter PH, Wider B, Ernst E. The antioxidant vitamins A, C, E and selenium in the treatment of arthritis: a systematic review of randomized clinical trials. Rheumatology 2007;46:1223-1233.
Kidd BL, Langford RM, Wodehouse T. Arthritis and pain. Current approaches in the treatment of arthritic pain. Arthritis Res Ther. 2007 ;9(3):214 PMID: 17572915
The information contained in the abstracts is not a personal health recommendation.
You should consult your own healthcare provider about decisions involved in your care.
Research Quality Grades: (1) = A+, (2) = A-, (3) = B, (4) = C, (5) = D *
*Quality of Evidence
(1) I: Evidence obtained from at least one properly randomized controlled trial. Well-designed and well-conducted meta-analyses were also considered, and were graded according to the quality of the studies on which the analyses were based (e.g., Grade I if the meta-analysis pooled properly randomized controlled trials). Please also note: occasionally randomized controlled trial studies may be given a lower grade due to other issues in the research design.
(2) II-1: Evidence obtained from well-designed controlled trials without randomization.
(3) II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
(4) II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.
(5) III: Opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees.
