The American College of Rheumatologists have released up-to-date guidelines for the treatment of hip, knee and hand osteoarthritis. These guidelines are based on a systematic review of current evidence. They give either strong or conditional recommendations FOR OR AGAINST many treatments for Osteoarthritis. While I agree with most of the recommendations, there are a few recommendations that are not as clear as they purport and some that I outrightly disagree.
What is the evidence for treatment of hip, knee and hand osteoarthritis?
1. There is no doubt that EXERCISE THERAPY improves pain and function of osteoarthritis. This should be composed of a mix of aerobic (such as walking or cycling) and resistance training. However, there is a insufficient evidence to recommend one form of exercise over another. However, it would seem that exercise is more effective if supervised by a therapist or personal trainer. I refer to physiotherapists who have an interest in rehabilitation such as Complete physio, Executive Physiotherapy, Third Space physio and Six Physio. There is less evidence to suggest that balance exercises are effective - although it would make sense to add these exercises to a programme. Other exercise programmes that might be useful include Tai Chi and Yoga with more evidence for Tai Chi.
2. In addition to exercise, WEIGHT LOSS also contributes to symptom-relief. This also seems to be dose dependent ie more weight loss leads to a greater effect.
3. BBRACES including patellofemoral braces or hand splints are recommended for knee and hand OA
4. There is no good evidence to suggest that acupuncture, manual therapy or other passive treatments are effective for OA
5. Medication - Medications should only be used as an adjunct to an exercise program and weight loss. There is good evidence to suggest that anti-inflammatory cream is effective for knee and hand osteoarthritis. In addition, capsaicin cream is effective for knee osteoarthritis. Anti-inflammatories tablets (such as ibuprofen) have been shown to be effective but you need to be careful of potential side effects. PARACETAMOL seems to be less effective that anti-inflammatories. DULOXETINE is a drug taken for chronic pain and seems to be quite effective for osteoarthritis. TRAMADOL is also conditionally recommended although I would avoid this drug due to harsh side effects. Potent drugs such as morphine should be avoided. Interestingly, 'health supplements' such as FISH OILS or GLUCOSAMINE are not recommended due to lack of evidence.
Regarding injection therapy, the guidelines suggest a strong recommendation for cortisone injections for the hip, knee and hand. While I agree that cortisone can be effective for acute pain, I disagree with the recommendation as the effect of cortisone is short acting AND there is some evidence that cortisone has a negative effect on cartilage and MAY accelerate the need for a joint replacement. I discuss potent side effects in a recent blog. There is also a strong recommendation against other injectants such as hyaluronic acid or platelet-rich plasma. However, these guidelines ignore the recent evidence for platelet-rich plasma injections for knee osteoarthritis as outlined in a recent blog. If you're contemplating injection therapy, I would favor image-guided injections. I discuss the issues of ultrasound-guided injections in this blog and I demonstrate a knee joint injection done under ultrasound here.