Some kinds of exercise recommended in OA. Lifestyle modification (such as weight loss and exercise) and pain medications are the mainstays of treatment. Acetaminophen (also known as paracetamol) is recommended first line with NSAIDs being used as add on therapy only if pain relief is not sufficient. Medications that alter the course of the disease have not been found as of 2018. Recommendations include modification of risk factors through targeted interventions including 1) obesity and overweight, 2) physical activity, 3) dietary exposures, 4) comorbidity, 5) biomechanical factors, 6) occupational factors. Lifestyle changes For overweight people, weight loss may be an important factor. Weight loss and exercise provides long-term treatment and advocated in patients with OA. As an adjunct to these lifestyle changes, use of analgesia, intra-articular cortisone injection and consideration of hyaluronic acids and platelet-rich plasma are recommended for pain relief in patients with knee osteoarthritis. Patient education has been shown to be helpful in the self-management of arthritis. It decreases pain, improves function, reduces stiffness and fatigue, and reduces medical usage. Patient education can provide on average 20% more pain relief when compared to NSAIDs alone. Physical measures Moderate exercise may be beneficial with respect to pain and function in those with osteoarthritis of the knee and hip. These exercises should occur at least three times per week. While some evidence supports certain physical therapies, evidence for a combined program is limited. Providing clear advice, making exercises enjoyable, and reassuring people about the importance of doing exercises may lead to greater benefit and more participation. Limited evidence suggests that supervised exercise therapy may improve exercise adherence. There is not enough evidence to determine the effectiveness of massage therapy. The evidence for manual therapy is inconclusive. A 2015 review indicated that aquatic therapy is safe, effective, and can be an adjunct therapy for knee osteoarthritis. Functional, gait, and balance training have been recommended to address impairments of position sense, balance, and strength in individuals with lower extremity arthritis, as these can contribute to a higher rate of falls in older individuals. For people with hand osteoarthritis, exercises may provide small benefits for improving hand function, reducing pain, and relieving finger joint stiffness. Lateral wedge insoles and neutral insoles do not appear to be useful in osteoarthritis of the knee. Knee braces may help but their usefulness has also been disputed. For pain management heat can be used to relieve stiffness, and cold can relieve muscle spasms and pain. Among people with hip and knee osteoarthritis, exercise in water may reduce pain and disability, and increase quality of life in the short term. Also therapeutic exercise programs such as aerobics and walking reduce pain and improve physical functioning for up to 6 months after the end of the program for people with knee osteoarthritis. Hydrotherapy might also be an advantage on the management of pain, disability and quality of life reported by people suffering from osteoarthritis. Medication Treatment recommendations by risk factors GI risk CVD risk Option Low Low NSAID, or paracetamol Moderate Low Paracetamol, or low dose NSAID with antacid Low Moderate Paracetamol, or low dose aspirin with an antacid Moderate Moderate Low dose paracetamol, aspirin, and antacid. Monitoring for abdominal pain or black stool. By mouth The pain medication paracetamol (acetaminophen) is the first line treatment for osteoarthritis. Pain relief does not differ according to dosage. However, a 2015 review found acetaminophen to have only a small short-term benefit with some laboratory concerns of liver inflammation. For mild to moderate symptoms effectiveness of acetaminophen is similar to non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen, though for more severe symptoms NSAIDs may be more effective. NSAIDs are associated with greater side effects such as gastrointestinal bleeding. Another class of NSAIDs, COX-2 selective inhibitors (such as celecoxib) are equally effective when compared to nonselective NSAIDs, and have lower rates of adverse gastrointestinal effects, but higher rates of cardiovascular disease such as myocardial infarction. They are also more expensive than non-specific NSAIDs. Benefits and risks vary in individuals and need consideration when making treatment decisions, and further unbiased research comparing NSAIDS and COX-2 selective inhibitors is needed. NSAIDS applied topically are effective for a small number of people. The COX-2 selective inhibitor rofecoxib was removed from the market in 2004, as cardiovascular events were associated with long term use. Failure to achieve desired pain relief in osteoarthritis after 2 weeks should trigger reassessment of dosage and pain medication. Opioids by mouth, including both weak opioids such as tramadol and stronger opioids, are also often prescribed. Their appropriateness is uncertain, and opioids are often recommended only when first line therapies have failed or are contraindicated. This is due to their small benefit and relatively large risk of side effects. The use of tramadol likely does not improve pain or physical function and likely increases the incidence of adverse side effects. Oral steroids are not recommended in the treatment of osteoarthritis. Use of the antibiotic doxycycline orally for treating osteoarthritis is not associated with clinical improvements in function or joint pain. Any small benefit related to the potential for doxycycline therapy to address the narrowing of the joint space is not clear, and any benefit is outweighed by the potential harm from side effects. Topical There are several NSAIDs available for topical use, including diclofenac. A Cochrane review from 2016 concluded that reasonably reliable evidence is available only for use of topical diclofenac and ketoprofen in people aged over 40 years with painful knee arthritis. Transdermal opioid pain medications are not typically recommended in the treatment of osteoarthritis. The use of topical capsaicin to treat osteoarthritis is controversial, as some reviews found benefit while others did not. Joint injections Ultrasound-guided hip joint injection: A skin mark is made to mark the optimal point of entry for the needle. Steroids Joint injection of glucocorticoids (such as hydrocortisone) leads to short-term pain relief that may last between a few weeks and a few months. A 2015 Cochrane review found that intra-articular corticosteroid injections of the knee did not benefit quality of life and had no effect on knee joint space; clinical effects one to six weeks after injection could not be determined clearly due to poor study quality. Another 2015 study reported negative effects of intra-articular corticosteroid injections at higher doses, and a 2017 trial showed reduction in cartilage thickness with intra-articular triamcinolone every 12 weeks for 2 years compared to placebo. A 2018 study found that intra-articular triamcinolone is associated with an increase in intraocular pressure. Hyaluronic acid Injections of hyaluronic acid have not produced improvement compared to placebo for knee arthritis, but did increase risk of further pain. In ankle osteoarthritis, evidence is unclear. Platelet rich plasma The effectiveness of injections of platelet-rich plasma is unclear; there are suggestions that such injections improve function but not pain, and are associated with increased risk. A Cochrane review of studies involving PRP found the evidence to be insufficient. Surgery Bone fusion Arthrodesis (fusion) of the bones may be an option in some types of osteoarthritis. An example is ankle osteoarthritis, in which ankle fusion is considered to be the gold standard treatment in end-stage cases. Joint replacement If the impact of symptoms of osteoarthritis on quality of life is significant and more conservative management is ineffective, joint replacement surgery or resurfacing may be recommended. Evidence supports joint replacement for both knees and hips as it is both clinically effective and cost-effective. People who underwent total knee replacement had improved SF-12 quality of life scores, were feeling better compared to those who did not have surgery, and may have short- and long-term benefits for quality of life in terms of pain and function. The beneficial effects of these surgeries may be time-limited due to various environmental factors, comorbidities, and pain in other regions of the body. For people who have shoulder osteoarthritis and do not respond to medications, surgical options include a shoulder hemiarthroplasty (replacing a part of the joint), and total shoulder arthroplasty (replacing the joint). Biological joint replacement involves replacing the diseased tissues with new ones. This can either be from the person (autograft) or from a donor (allograft). People undergoing a joint transplant (osteochondral allograft) do not need to take immunosuppressants as bone and cartilage tissues have limited immune responses. Autologous articular cartilage transfer from a non-weight-bearing area to the damaged area, called osteochondral autograft transfer system, is one possible procedure that is being studied. When the missing cartilage is a focal defect, autologous chondrocyte implantation is also an option. Shoulder replacement For those with osteoarthritis in the shoulder, a complete shoulder replacement is sometimes suggested to improve pain and function. Demand for this treatment is expected to increase by 750% by the year 2030. There are different options for shoulder replacement surgeries, however, there is a lack of evidence in the form of high-quality randomized controlled trials, to determine which type of shoulder replacement surgery is most effective in different situations, what are the risks involved with different approaches, or how the procedure
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