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homeostasis of the joint.90 However there is minimal evidence for a role in long term disease modification. Intra-articular injection of sodium hyaluronate, also referred to as viscosupplementation, has been shown to be safe and possibly effective for symptomatic relief of knee osteoarthritis.90 The evidence for HA efficacy is mostly in knee OA, with a slower onset of action but more durable response than IA corticosteroid injection.
Tricyclic antidepressants
Tricyclic antidepressants (TCAs) work by blocking the uptake of serotonin and noradrenaline from synapses in the brain and spinal cord. These neurotransmitters are involved in inhibiting pain signals, and blocking their removal from synapses improves the body’s inhibition of pain signals.
Theoretically, TCAs should be helpful in OA pain, but only one study has explored this. The study was inconclusive in terms of pain relief, but support is emerging for the benefits of TCAs in OA pain.40
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risk for the progression of OA.59 Studies have found that excessive amounts of fatty tissue, termed adipose tissue, result in the release of specific hormones and growth factors.92
Weight reduction relieves stress on the affected knees. The benefits of weight loss, whether obtained through regular exercise and diet or through surgical intervention, may extend not only to symptom relief but also to a slowing in cartilage loss in weight bearing joints (eg, knees).92 In addition, weight loss lowers the levels of the inflammatory cytokines and adipokines that may play a role in cartilage degradation.93
Exercise: Exercise provides benefit even if weight loss is not achieved or required, and has a role in both symptom management and as a preventive strategy. Patients may prefer organised instruction when using exercise to manage OA.94 Patients who believe that exercise is harmful to their joints are less likely to participate in exercise. Therefore, specific advice to exercise alongside education about the benefits and appropriate referral by family physicians may assist in overcoming this barrier to exercise participation.95 Exercise is an effective treatment for this condition, producing improvements in pain, physical function, and walking distance. Long-term walking and resistance-training programs have been shown to slow the functional decline seen in many patients with osteoarthritis, including older patients.95
Both local muscle strengthening and aerobic exercises have been found to be effective in the treatment of OA of the knee.96 Recent meta-analysis supports the recommendations that muscle strengthening exercise leads to improvements in strength, pain, function, and quality of life.96 Muscle strengthening is a key component of exercise for osteoarthritis because of the relation between muscle weakness and pain and function. Both high and low intensity aerobic exercise appears to be equally effective in improving a patient’s functional status, gait, pain and aerobic capacity for people with OA of the knee.96
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Patient education: Good communication between healthcare professionals and patients is essential. People with osteoarthritis should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.40 Healthcare professionals should offer accurate verbal and written information to all patients with osteoarthritis to enhance understanding of the condition and its management, and to counter misconceptions that OA inevitably progresses and cannot be treated. Information sharing should be an ongoing and integral part of the management plan rather than a single event at time of presentation.40 Patient education has been shown to be helpful in the self-management of arthritis.
It decreases pain, improving function, reducing stiffness and fatigue, and reducing medical usage.
A meta-analysis has shown that patient education can provide on average 20% more pain relief when compared to NSAIDs alone in patients with hip OA.97
Physical therapy: There is some evidence to support the use of physical therapy (which includes a range of different therapeutic strategies and usually incorporates manual therapy such as muscle stretching and passive range of movement strategies).1
Thermotherapy: The local application of heat or cold (cryotherapy) to a painful joint has been used for many years in the rehabilitation of patients with OA to relieve pain, stiffness and oedema.98
Cryotherapy is usually administered by application of cold packs or massage with ice over painful areas or acupoints. Cold application helps to reduce pain and swelling by causing temporary vasoconstriction and a reduction in local blood flow. This may in turn help improve range of motion and function. Heat therapy is used to reduce pain and stiffness by possibly improving circulation and relaxing muscles. However there are concerns that increased blood flow may worsen inflammation and oedema. Common methods of superficial heat administration are
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electrical heating pads, application of hot packs, towels or wax, or immersion in warm water or wax baths.99
For knee osteoarthritis, ice massage may be a useful adjunct for pain relief and cold packs may be used to lessen knee oedema. Ice packs did not affect pain significantly compared to controls;
however ice massage did have a significant effect. A study has shown that heat therapy for knee OA used for 20 minutes every other day for four weeks can significantly improve pain and disability but not stiffness.100 Local application of heat prior to exercise may be helpful in knee OA. Despite these evidences further studies are required to determine their efficacy
Occupational therapy: Occupational adjustments may be necessary for some patients with osteoarthritis. An occupational therapist can assist with evaluating how well the patient performs activity of daily living (ADLs), as well as with retraining of the patient as necessary. Joint-protection techniques should be emphasized.70
Psychosocial interventions: Socioeconomic and psychosocial factors have an important role in establishing the burden of osteoarthritis on an individual. The American college of rheumatology has recommended the use of psychosocial interventions in the management of patients with osteoarthritis of the knee.70 Psychosocial approaches to managing OA include psycho-educational programs, coping skills training (CST) and cognitive behavioural therapy (CBT).40 Psychosocial interventions are necessary in patients with osteoarthritis because of the effect of the disease on the patient and the family. Psychosocial interventions can help to improve patients knowledge, acceptance, and promote appropriate use of drug therapy. Other benefits of psychosocial interventions include enhanced self-esteem and increase in the likelihood of treatment compliance.108 Patients are more likely to feel satisfied with the services and have significant gains in social functioning as well as improved quality of life.101 Psychological disruptions in each case vary because disease severity, coping capability and the resilience of individuals and families
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vary to the disease. Studies administering psychological support as an adjunct to regular medical care have shown encouraging results.101
Psycho-education is one of the psychosocial interventions employed in the management of patients with osteoarthritis of the knee. It involves educating the patient on the risk, course, care and coping mechanisms of the disease. National Institute for Health and Clinical Excellence (NICE) guidelines on the care and management of adults with osteoarthritis requires physicians to ask these patients about: 40
Current thoughts and beliefs - their concerns, expectations, knowledge about OA.
Their support network - is there a care giver? If so, how is the main supporter coping (their ideas, concerns and expectations)?
Current mood (screen for depression) - any other stress?
Attitude to exercise.
Effect of OA on their life (e.g. activities of daily living, family tasks, work, hobbies, sleep, lifestyle expectations). Are any adjustments required at home or in the workplace?
Pain - what has the patient tried, including any drugs used (dose, side-effects, timing)? Are there other treatable sources of pain (eg periarticular pain)? Has a chronic pain syndrome developed?
Any comorbidities that may affect choice of treatment or fitness for surgery. Is the patient prone to falls - and can this be minimised?