25 Treatments for Arthritis Hip and Knee Pain
Guidelines recommend combining drugs with non-medicinal remedies.
When it comes to treating osteoarthritis in your knees and hips, you may have more options than you realize. In February 2008, the Osteoarthritis Research Society International (OARSI), a nonprofit organization dedicated to promoting osteoarthritis research and treatment, published its first evidence-based recommendations for treatment of osteoarthritis of the hip and knee. The goal was to eliminate inconsistent treatment approaches by creating simple guidelines that would enable health care providers to determine which therapies would be most useful for an individual patient.
The committee took the scientifically proven commonalities it found in the international literature, evaluated the level of scientific evidence, proposed a strength of recommendation for each modality, and then condensed them into a comprehensive “playbook” of 25 treatment recommendations. The first of the 25 recommendations is to combine drug and non-drug treatments for optimal results. The remaining 24 fall into three categories: non-drug, drug and surgical. Following are the 25 recommenda
tions with updates and links to further reading by Arthritis Today.
1. Drug and non-drug treatments. The optimal osteoarthritis (OA) treatment program should consist of both medications and non-drug treatments.
Non-drug Treatments
2. Education and self-management. The initial focus of treatment should be on what patients can do for themselves, rather than on passive therapies delivered by a health professional.
3. Regular telephone contact. The best evidence for the benefit of phone contact came from a study of 439 OA patients in which monthly phone calls from lay personnel promoting self-care were associated with improvements in joint pain and physical function for up to a year.
4. Physical therapy. Studies consistently support the usefulness of an evaluation by a physical therapist and instruction in appropriate exercise to reduce pain and improve function. Physical therapists can also provide assistive devices to make daily tasks easier.
5. Aerobic, muscle-strengthening and water-based exercises. A rounded exercise program can promote muscle strength, improve range of motion, increase mobility and ease pain.
6. Weight loss. Maintaining your recommended weight or losing weight if you are overweight can lessen your pain by reducing stress on your affected joints. Weight loss specifically helps ease pressure on weight-bearing joints such as the hips and knees.
7. Walking aids. Canes and crutches can reduce pain in hip and knee or OA. If both hips and/or knees are affected wheeled walkers may be preferable.
8. Footwear and insoles. If osteoarthritis affects the knee, special footwear and insoles can reduce pain and improve walking.
9. Knee braces. For osteoarthritis with associated knee instability, a knee brace can reduce pain, improve stability and reduce the risk of falling.
10. Heat and cold. Many people find the heat of a warm bath, heat pack or paraffin bath eases OA pain. Others find relief in cold packs. Still others prefer alternating the two.
11. Transcutaneous electrical nerve stimulation (TENS). A technique in which a weak electric current is administered through electrodes placed on the skin, TENS is believed to stop messages from pain receptors from reaching the brain. It has been shown to help with short-term pain control in some patients with knee or hip arthritis.
12. Acupuncture. A form of traditional Chinese medicine involving the insertion of thin, sharp needles at specific points on the body, acupuncture has been touted as a treatment for osteoarthritis pain. A recent trial of 352 patients with knee osteoarthritis showed small but statistically significant improvement in pain intensity two and four weeks after a course of acupuncture.
Drug Treatments
13. Acetaminophen is part of a group of pain-treating medications called analgesics. At a dosage of up to 4 grams per day, acetaminophen (Tylenol), can be an effective initial treatment for osteoarthritis pain. The American College of Rheumatology (ACR) recommends acetaminophen as the initial treatment for osteoarthritis of the hip and knee.
14. Nonsteroidal anti-inflammatory drugs. Despite cardiovascular and gastrointestinal concerns about this class of drugs, the committee concludes NSAIDs can be useful for OA pain, but advises using at the lowest effective dosages and avoiding long-term use if possible. In people at high risk of gastrointestinal side effects, the committee recommends a COX-2 inhibitor or a traditional NSAID along with proton pump inhibitor or other stomach-protective drug.
15. Topical analgesics (NSAIDs and Capsaicin). Topical NSAIDs and capsaicin, an analgesic derived from chili peppers, can be used along with or instead of oral analgesics or NSAIDs for OA pain. One of them, Voltaren Gel, is a topical formulation of the NSAID diclofenac, and is available only by prescription.
16. Corticosteroid injections. Injecting corticosteroid compounds directly into affected joints can be useful when there is localized inflammation and/or moderate to severe pain that doesn’t respond to oral pain relievers. The ACR recommends corticosteroid injections as an alternate initial therapy to acetaminophen for patients who have moderate to severe knee pain and signs of inflammation and who do not get relief from acetaminophen. You can have corticosteroid injections in the same joint three to four times per year.
17. Hyalruonic acid injections. A series of injections of hyaluronic acid, meant to supplement a natural substance that gives joint fluid its viscosity, may be useful in treating the pain of hip and knee arthritis, according to the experts. However, a recent study published in Arthritis & Rheumatism found a single intraarticular injection of hyaluronic acid for the treatment of hip osteoarthritis was ineffective in achieving significant pain relief in comparison to placebo.
18. Glucosamine and/or chondroitin for symptom relief. Treatment with one or both of these supplements may provide symptomatic benefit for some people with knee osteoarthritis. However, the experts advise discontinuing them if you don’t notice any relief within six months.
19. Glucosamine sulfate, chondroitin and/or diacerein for possible structure-modifying effects. There is some evidence that glucosamine or chondroitin may not only ease symptoms but may slow or halt cartilage breakdown in osteoarthritis. Similar effects have been seen with the osteoarthritis medication diacerein. (Diacerein is not approved in the U.S.)
20. Opioid and narcotic analgesics. The use of weak opioids and narcotic analgesics can be considered for patients who cannot tolerate other medications or for whom other medications are not effective, according to recommendations. Stronger opioids should be used only for the management of severe pain in “exceptional circumstances.”
Surgery
21. Joint replacement surgery. When symptoms of knee or hip OA are not controlled with drug and non-drug treatments, replacing the joint with a prosthesis is often effective.
22. Unicompartmental knee replacement. Approximately 30 percent of people with knee osteoarthritis have disease that is largely restricted to one area of the joint. In these cases, unicompartmental knee replacement (also called partial knee replacement) may offer the same improvement and function as total knee replacement but with less trauma and better range of motion.
23. Osteotomy and joint-preserving surgery. For young, active people with hip or knee osteoarthritis, osteotomy (a procedure in which bones are cut and realigned to improve joint alignment) may delay the need for joint replacement by years.
24. Joint lavage and arthroscopic debridement. The roles of joint lavage (flushing the joint with a sterile saline solution) and arthroscopic debridement (the surgical removal of tissue fragments from the joint) are controversial. Some studies have shown short-term relief; however, a 2008 Cochrane Review by the Cochrane Collaboration – an international not-for-profit organization, providing up-to-date information about the effects of health care – shows that in people with osteoarthritis arthroscopic debridement probably does not improve pain or ability to function compared to placebo (sham surgery).
25. Joint fusion when replacement has failed. When knee replacement fails, joint fusion (a procedure in which the bones that form the joint are surgically prepared and then held in place with screws, pins or plates until they fuse into a single rigid unit) can be considered a salvage procedure.
Guidelines recommend combining drugs with non-medicinal remedies.
When it comes to treating osteoarthritis in your knees and hips, you may have more options than you realize. In February 2008, the Osteoarthritis Research Society International (OARSI), a nonprofit organization dedicated to promoting osteoarthritis research and treatment, published its first evidence-based recommendations for treatment of osteoarthritis of the hip and knee. The goal was to eliminate inconsistent treatment approaches by creating simple guidelines that would enable health care providers to determine which therapies would be most useful for an individual patient.
The committee took the scientifically proven commonalities it found in the international literature, evaluated the level of scientific evidence, proposed a strength of recommendation for each modality, and then condensed them into a comprehensive “playbook” of 25 treatment recommendations. The first of the 25 recommendations is to combine drug and non-drug treatments for optimal results. The remaining 24 fall into three categories: non-drug, drug and surgical. Following are the 25 recommenda
tions with updates and links to further reading by Arthritis Today.
1. Drug and non-drug treatments. The optimal osteoarthritis (OA) treatment program should consist of both medications and non-drug treatments.
Non-drug Treatments
2. Education and self-management. The initial focus of treatment should be on what patients can do for themselves, rather than on passive therapies delivered by a health professional.
3. Regular telephone contact. The best evidence for the benefit of phone contact came from a study of 439 OA patients in which monthly phone calls from lay personnel promoting self-care were associated with improvements in joint pain and physical function for up to a year.
4. Physical therapy. Studies consistently support the usefulness of an evaluation by a physical therapist and instruction in appropriate exercise to reduce pain and improve function. Physical therapists can also provide assistive devices to make daily tasks easier.
5. Aerobic, muscle-strengthening and water-based exercises. A rounded exercise program can promote muscle strength, improve range of motion, increase mobility and ease pain.
6. Weight loss. Maintaining your recommended weight or losing weight if you are overweight can lessen your pain by reducing stress on your affected joints. Weight loss specifically helps ease pressure on weight-bearing joints such as the hips and knees.
7. Walking aids. Canes and crutches can reduce pain in hip and knee or OA. If both hips and/or knees are affected wheeled walkers may be preferable.
8. Footwear and insoles. If osteoarthritis affects the knee, special footwear and insoles can reduce pain and improve walking.
9. Knee braces. For osteoarthritis with associated knee instability, a knee brace can reduce pain, improve stability and reduce the risk of falling.
10. Heat and cold. Many people find the heat of a warm bath, heat pack or paraffin bath eases OA pain. Others find relief in cold packs. Still others prefer alternating the two.
11. Transcutaneous electrical nerve stimulation (TENS). A technique in which a weak electric current is administered through electrodes placed on the skin, TENS is believed to stop messages from pain receptors from reaching the brain. It has been shown to help with short-term pain control in some patients with knee or hip arthritis.
12. Acupuncture. A form of traditional Chinese medicine involving the insertion of thin, sharp needles at specific points on the body, acupuncture has been touted as a treatment for osteoarthritis pain. A recent trial of 352 patients with knee osteoarthritis showed small but statistically significant improvement in pain intensity two and four weeks after a course of acupuncture.
Drug Treatments
13. Acetaminophen is part of a group of pain-treating medications called analgesics. At a dosage of up to 4 grams per day, acetaminophen (Tylenol), can be an effective initial treatment for osteoarthritis pain. The American College of Rheumatology (ACR) recommends acetaminophen as the initial treatment for osteoarthritis of the hip and knee.
14. Nonsteroidal anti-inflammatory drugs. Despite cardiovascular and gastrointestinal concerns about this class of drugs, the committee concludes NSAIDs can be useful for OA pain, but advises using at the lowest effective dosages and avoiding long-term use if possible. In people at high risk of gastrointestinal side effects, the committee recommends a COX-2 inhibitor or a traditional NSAID along with proton pump inhibitor or other stomach-protective drug.
15. Topical analgesics (NSAIDs and Capsaicin). Topical NSAIDs and capsaicin, an analgesic derived from chili peppers, can be used along with or instead of oral analgesics or NSAIDs for OA pain. One of them, Voltaren Gel, is a topical formulation of the NSAID diclofenac, and is available only by prescription.
16. Corticosteroid injections. Injecting corticosteroid compounds directly into affected joints can be useful when there is localized inflammation and/or moderate to severe pain that doesn’t respond to oral pain relievers. The ACR recommends corticosteroid injections as an alternate initial therapy to acetaminophen for patients who have moderate to severe knee pain and signs of inflammation and who do not get relief from acetaminophen. You can have corticosteroid injections in the same joint three to four times per year.
17. Hyalruonic acid injections. A series of injections of hyaluronic acid, meant to supplement a natural substance that gives joint fluid its viscosity, may be useful in treating the pain of hip and knee arthritis, according to the experts. However, a recent study published in Arthritis & Rheumatism found a single intraarticular injection of hyaluronic acid for the treatment of hip osteoarthritis was ineffective in achieving significant pain relief in comparison to placebo.
18. Glucosamine and/or chondroitin for symptom relief. Treatment with one or both of these supplements may provide symptomatic benefit for some people with knee osteoarthritis. However, the experts advise discontinuing them if you don’t notice any relief within six months.
19. Glucosamine sulfate, chondroitin and/or diacerein for possible structure-modifying effects. There is some evidence that glucosamine or chondroitin may not only ease symptoms but may slow or halt cartilage breakdown in osteoarthritis. Similar effects have been seen with the osteoarthritis medication diacerein. (Diacerein is not approved in the U.S.)
20. Opioid and narcotic analgesics. The use of weak opioids and narcotic analgesics can be considered for patients who cannot tolerate other medications or for whom other medications are not effective, according to recommendations. Stronger opioids should be used only for the management of severe pain in “exceptional circumstances.”
Surgery
21. Joint replacement surgery. When symptoms of knee or hip OA are not controlled with drug and non-drug treatments, replacing the joint with a prosthesis is often effective.
22. Unicompartmental knee replacement. Approximately 30 percent of people with knee osteoarthritis have disease that is largely restricted to one area of the joint. In these cases, unicompartmental knee replacement (also called partial knee replacement) may offer the same improvement and function as total knee replacement but with less trauma and better range of motion.
23. Osteotomy and joint-preserving surgery. For young, active people with hip or knee osteoarthritis, osteotomy (a procedure in which bones are cut and realigned to improve joint alignment) may delay the need for joint replacement by years.
24. Joint lavage and arthroscopic debridement. The roles of joint lavage (flushing the joint with a sterile saline solution) and arthroscopic debridement (the surgical removal of tissue fragments from the joint) are controversial. Some studies have shown short-term relief; however, a 2008 Cochrane Review by the Cochrane Collaboration – an international not-for-profit organization, providing up-to-date information about the effects of health care – shows that in people with osteoarthritis arthroscopic debridement probably does not improve pain or ability to function compared to placebo (sham surgery).
25. Joint fusion when replacement has failed. When knee replacement fails, joint fusion (a procedure in which the bones that form the joint are surgically prepared and then held in place with screws, pins or plates until they fuse into a single rigid unit) can be considered a salvage procedure.
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