Spine Osteoarthritis Treatment, Exercise, Life Style

There is no cure for osteoarthritis, but there are many treatments that can relieve symptoms and significantly improve the quality of life.

The goals of osteoarthritis treatment are to reduce pain and improve joint function. Treatment approaches include

American College of Rheumatology guidelines

The American College of Rheumatology (ACR) has issued guidelines for pharmacologic treatment of osteoarthritis of the hand, hip, and knee.  For hand osteoarthritis, the ACR conditionally recommends using one or more of the following

• Topical capsaicin
• Topical nonsteroidal anti-inflammatory drugs (NSAIDs), including trolamine salicylate
• Oral NSAIDs
• Tramadol

The ACR conditionally recommends against using intra-articular therapies or opioid analgesics for hand osteoarthritis. For patients 75 years and older, the ACR conditionally recommends the use of topical rather than oral NSAIDs.

For knee osteoarthritis, the ACR conditionally recommends using one of the following:

• Acetaminophen
• Oral NSAIDs
• Topical NSAIDs
• Tramadol
• Intra-articular corticosteroid injections

The ACR conditionally recommends against using chondroitin sulfate, glucosamine, or topical capsaicin for knee osteoarthritis. The ACR has no recommendations regarding the use of intra-articular hyaluronates, duloxetine, and opioid analgesics.

For hip osteoarthritis, the ACR conditionally recommends using one or more of the following for initial management:

• Acetaminophen
• Oral NSAIDs
• Tramadol
• Intra-articular corticosteroid injections

The ACR conditionally recommends against using chondroitin sulfate or glucosamine for hip osteoarthritis. The ACR has no recommendation regarding the use of topical NSAIDs, intra-articular hyaluronate injections, duloxetine, or opioid analgesics.

American Academy of Orthopaedic Surgeons guidelines

• Oral NSAIDs
• Topical NSAIDs
• Tramadol

The AAOS was unable to recommend for or against the use of the following for symptomatic knee osteoarthritis

• Acetaminophen
• Opioids
• Pain patches
• Intra-articular corticosteroid injections
• Growth factor injections and/or platelet rich plasma

The recommendation on acetaminophen is a downgrade from the previous AAOS guideline and reflects the use of new criteria that resulted in the selection of only one study, which found no statistical significance or minimum clinically important improvement with acetaminophen compared with placebo.

The AAOS does not recommend treatment with any of the following

• Intra-articular hyaluronic acid
• Glucosamine and/or chondroitin sulfate or hydrochloride

Agency for Healthcare Research and Quality findings

A comparison of analgesics for osteoarthritis carried out by the Agency for Healthcare Research and Quality (AHRQ) found that “no currently available analgesic reviewed in this report offers a clear overall advantage compared with the others. The choice of analgesic for an individual patient should take into account the trade-off between benefits and adverse effects, which differs across analgesics. Patient age, comorbid conditions, and concomitant medication are key considerations.

The AHRQ comparison found that acetaminophen was modestly inferior to NSAIDs in reducing osteoarthritis pain but was associated with a lower risk of GI adverse effects.  On the other hand, acetaminophen poses a higher risk of liver injury.

AHRQ findings on adverse effects included the following

• Selective NSAIDs as a class were associated with a lower risk of ulcer complications than were the nonselective NSAIDs naproxen, ibuprofen, and diclofenac
• The partially selective NSAIDs meloxicam and etodolac were associated with a lower risk of ulcer-related complications and symptomatic ulcers than were various nonselective NSAIDs
• The risk of serious GI adverse effects was found to be higher with naproxen than with ibuprofen
• Celecoxib and the nonselective NSAIDs ibuprofen and diclofenac were associated with an increased risk of cardiovascular adverse effects when compared with placebo
• The nonselective NSAIDs ibuprofen and diclofenac, but not naproxen, were associated with an increased risk of heart attack when compared with placebo

The AHRQ noted that topical diclofenac was found to have efficacy similar to that of oral NSAIDs in patients with localized osteoarthritis. No head-to-head trials compared topical salicylates or capsaicin with oral NSAIDs for osteoarthritis.

Medications

The goal of treatment is to decrease pain and increase mobility.

Patients should use only the lowest effective dose because high dosages of NSAIDs can cause heart problems (such as increased blood pressure and risk of heart attack), kidney problems, and stomach bleeding. Because of these risks, the American College of Rheumatology recommends using topical NSAIDs in place of oral NSAIDs for patients 75 years and older.

Patients who take daily low-dose aspirin for heart protection should consider using an oral NSAID other than ibuprofen. Ibuprofen may make the aspirin less effective.

Patients who are at increased risk of stomach bleeding and ulcers should either switch to another type of pain reliever, or take the NSAID along with a proton-pump inhibitor drug, such as omeprazole (Prilosec, generic) or esomeprazole (Nexium), an H2 blocker such as famotidine (Pepcid, generic), or with the synthetic prostaglandin misoprostol (Cytotec, generic). (Misoprostol can cause miscarriage and should not be used by women who may be pregnant.) Some NSAIDs are available as combination pills; they include diclofenac/misoprostol (Arthrotec) and ibuprofen/famotidine (Duexis)

Ibuprofen, Voltaren topical gel, and Ultram 50mg. | Source

Your physical therapist can help with a variety of treatment options, including

Exercise

Joints need motion to stay healthy. Long periods of inactivity cause the arthritic joint to stiffen and the adjoining tissue to atrophy (waste away). A moderate exercise program that includes low-impact aerobics and power and strength training has benefits for patients with osteoarthritis, even if exercise does not slow down the disease progression. Exercise helps

• Reduce stiffness and increase flexibility. It may also help improve the strength and elasticity of knee cartilage.
• Promote weight loss.
• Improve strength, which in turn improves balance and endurance.
• Reduce stress and improve feelings of well being, which helps patients cope with the emotional burden of pain.

Caution –  Please consult your physical therapist or doctor before starting any exercise program.

Stretching – Your physical therapist will prescribe specific stretching exercises for your spine, arms, or legs based on the results of your initial evaluation. Obese individuals are in special need of stretching and exercises. Combined with strengthening, stretching may help slow the progression of the disease.

Symptom management – Symptom management means learning to feel better and remain active. Sometimes people are fearful that increased activity will worsen their symptoms or increase their pain. Your physical therapist will help you learn how to be more active without worsening your symptoms. He or she will help you find your appropriate activity levels and develop a unique program to keep you moving.

Daily activity training – Your physical therapist can teach you how to get in and out of bed, in and out of the bathtub, or out of a chair, and how to bend and walk with more ease.

Use of modalities – Treatment “modalities” such as heat or ice may be used to help manage your symptoms.

Manual therapy – Your physical therapist may use gentle hands-on techniques (manual therapy) to help improve your spinal flexibility and ease stiffness.

Balance and walking training – Exercises and instruction may be used to improve your balance safely and reduce your risk of falls.

Specialized braces or taping – Your physical therapist may use taping or specialized braces to help support your joints. Back bracing is used most in more advanced conditions.

Weight control – If you are obese, you are likely to have more spinal impairment in your upper back. Your physical therapist can help you improve your activity levels, and refer you to nutritional experts.

Remember, all cases of OA of the spine are different. Your physical therapist will choose the best treatment options for you based on his or her evaluation of your specific problem.

Exercise especially helps patients with mild-to-moderate osteoarthritis in the hip or in the knee. Many patients who begin an aerobic or resistance exercise program report less disability and pain. They are better able to perform daily chores and remain more independent than their inactive peers. Older patients and those with medical problems should always check with their doctors before starting an exercise program.

Three types of exercise are best for people with osteoarthritis:

• Strengthening and resistance exercise
• Range-of-motion exercise
• Aerobic, or endurance, exercise

Strengthening and Resistance Exercise

Strengthening exercises include isometric exercises (pushing or pulling against static resistance). Isometric training builds muscle strength while burning fat, helps maintain bone density, and improves digestion. For patients with arthritis in the hip or knees, exercises that strengthen the muscles of the upper leg are important.

Exercise, such as weightlifting, helps build muscle that is usually lost with age and puts stress on bones, helping keep them strong and healthy.

Range-of-Motion Exercise

These exercises increase the amount of movement in the joints. In general, they are stretching exercises. The best examples are yoga and tai chi, which focus on flexibility, balance, and proper breathing.

Aerobic Exercise

Aerobic exercises help control weight and may reduce inflammation in some joints. Low-impact workouts also help stabilize and support the joint. Cycling and walking are beneficial, and swimming or exercising in water is highly recommended, for people with arthritis. (Patients with osteoarthritis should avoid high-impact sports, such as jogging, tennis, and racquetball if they cause pain.

Occupational Therapy

In addition to exercise, treatment of muscles and joints by a physical therapist can be helpful. An occupational therapist can show you ways to more easily perform daily tasks of living without putting stress on your joints. Your therapist can recommend how to make changes in your workplace or work tasks to avoid repetitive or damaging motions.

Weight Reduction

Overweight patients with osteoarthritis can lessen the shock on their joints by losing weight. Knees, for example, sustain an impact three to five times the body weight when descending stairs. Losing 5 pounds of weight can eliminate 20 pounds of stress on the knee. The greater the weight loss, the greater the benefit.

Heat and Ice

Ice. When a joint is inflamed (particularly in the knee) applying ice for 20 – 30 minutes can be helpful. If an ice pack is not available, a package of frozen vegetables works just as well.

Heat Treatments. Soaking in a warm bath or applying a heating pad may help relieve stiffness and pain.

Mechanical Aids

A wide variety of devices are available to help support and protect joints. They include splints or braces, and shoe inserts or orthopedic shoes. A commonly used brace for knee osteoarthritis that involves only one side of the knee joint is called an offloading brace.

Assistive Devices

There are many different types of assisted devices that can help make your life easier in the home. Kitchen gadgets, such as jar openers, can assist with gripping and grabbing. Door-knob extenders and key turners are helpful for patients who have trouble turning their wrists. Bathrooms can be fitted with shower benches, grip bars, and raised toilet seats. An occupational therapist can advise you on choosing the right kinds of assistive devices.

Acupuncture

Pain Management

Relaxation techniques such as guided imagery and breathing exercises may help some patients better cope with chronic pain.

Acupuncture, Transcutaneous Electric Nerve Stimulation (TENS), Therapeutic Ultrasound, and Massage

Some patients use acupuncture to reduce osteoarthritis pain. The technique is painless and involves the insertion of small fine needles at select points in the body. Some studies have found that acupuncture can help provide short-term pain relief for knee osteoarthritis.

Transcutaneous electric nerve stimulation (TENS) uses low-level electrical pulses to suppress pain. A variant (sometimes called percutaneous electrical nerve stimulation, or PENS) applies these pulses through a small needle to acupuncture points. Some patients with knee osteoarthritis find this treatment helpful.

Ultrasound therapy uses high-energy sound waves to produce heat within the tissue, which may help reduce inflammation, relieve pain, and improve function. Therapeutic ultrasound is usually performed by a physical therapist using an ultrasound machine. The therapist applies gel to the affected area and moves a handheld ultrasound transducer over the joint. Some evidence suggests that therapeutic ultrasound may be beneficial for patients with knee osteoarthritis.

Massage therapy may also help provide short-term pain relief. It is important to work with an experienced massage therapist who understands how not to injure sensitive joint areas.

Herbs and Dietary Supplements

Glucosamine and Chondroitin 

Glucosamine hydrochloride and chondroitin sulfate are natural substances that are part of the building blocks found in and around cartilage. For many years, researchers have been studying whether these dietary supplements really work for relieving osteoarthritis pain. Earlier studies suggested a potential benefit from these supplements.

However, several recent high-quality studies involving large numbers of patients have indicated that glucosamine and chondroitin, either alone or in combination, do not seem to work any better than a placebo for relieving symptoms of osteoarthritis. Based on these studies, the American College of Rheumatology does not recommend the use of these supplements. Some doctors suggest a trial period of three months to see if glucosamine and chondroitin work. If the patient does not experience any benefit, the supplements should be discontinued.

S-adenosylmethionine (SAMe)

S-adenosylmethionine (SAMe, pronounced “Sammy”) is a synthetic form of a natural byproduct of the amino acid methionine. It has been marketed as a remedy for arthritis, but scientific evidence supporting these claims is lacking.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body’s chemistry, and therefore have the potential to produce side effects that may be harmful. There have been several reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Arthroscopy and Debridement

Arthroscopy is performed to clean out bone and cartilage fragments (debridement) that, in theory at least, may cause pain and inflammation. It is also sometimes used to diagnose osteoarthritis. In this procedure, the surgeon makes a small incision and inserts the arthroscope, a pencil-width fiber-optic instrument that contains a light and magnifying lens. The arthroscope is attached to a miniature television camera that allows the surgeon to see the inside of the joint.

Research and debate continue on whether arthroscopy provides true benefits for those with osteoarthritis and, if so, which patients may benefit the most from it. Arthroscopy is most likely to benefit people with mild-to-moderate osteoarthritis who have evidence of bone and cartilage fragments in the joint, or patients whose joints lock or catch with movements

Joint Replacement (Arthroplasty)

When osteoarthritis becomes so severe that pain and immobility make normal functioning impossible, many people become candidates for artificial (prosthetic) joint implants using a procedure called arthroplasty. Hip replacement is the most established and successful replacement procedure, followed by knee replacement. Other joint surgeries (such as shoulders, elbows, wrists, and fingers) are less common, and some arthritic joints (in the spine, for instance) cannot yet be treated in this manner. When two joints, such as both knees, need to be replaced, having the operations done sequentially rather than at the same time may result in fewer complications

Candidates. The primary indications for surgery are pain and significant limitations of movement, including walking, that cannot be treated by less invasive therapies.

Patients who may not be good candidates are those with the following conditions:

• Severe neurologic, emotional, or mental disorders
• Severe osteoporosis
• Other chronic medical conditions
• Obesity

Surgeons often prefer to delay prosthetic implantation in younger patients, because implants wear out and the patient will need at least one revision procedure later on. Newer, longer-lasting materials, however, may help reduce the rate of revision operations.

Elderly patients with poorly controlled osteoarthritis often do very well after joint replacement surgery. While full recovery may take older patients longer to achieve than younger people, the long-term outcome of the surgery is usually excellent and can lead to significant improvements in pain and quality of life.

Complications

• Complications can occur, and, although uncommon, some can be life-threatening. In addition to blood loss and infection, deep blood clots in the legs (deep venous thrombosis) are a serious potential complication. These clots can potentially travel to the lungs (pulmonary embolism) and pose a risk for death. Patients who are overweight are at higher than average risk for blood clots.
• Recovery and Rehabilitation. Aside from the surgeon’s skill and the patient’s underlying condition, the success rate depends on the kind and degree of activity the joint receives following replacement surgery. Physical therapy takes about 6 weeks to rebuild adjoining muscle and strengthen surrounding ligaments. Patients typically experience considerable pain during this time.
• While many patients find that joint replacement eventually provides pain relief and restores some mobility, they need time to adjust to the artificial joint.

Limitations after hip surgery include:

• Usually, patients with new hips are able to walk several miles a day and climb stairs, but they cannot run.
• Prosthetic hips should not be flexed beyond 90 degrees, so patients must learn new ways to perform activities requiring bending down (like tying a shoe).

Limitations after knee surgery include:

• Walking distance improves after knee replacement surgery, but patients still cannot run.
• Artificial knee joints generally have a limited range of motion of just 110 degrees and stair climbing may remain difficult.

Minimally Invasive Arthroplasty – Surgeons are exploring a variety of new techniques for a “minimally invasive” approach to knee and hip arthroplasty. They include using a shorter incision, and new types of smaller specialized instruments. The goal is to give the patient a shorter recovery time and less postoperative pain. However, minimally invasive arthroplasty is still in its early stages. At this time, there is no consensus on which minimally invasive technique works best, or if it actually achieves any additional benefits beyond the recovery period.

Hip Resurfacing – Hip resurfacing is a surgical alternative to total hip replacement. It involves scraping the surfaces of the hip joint and femur and placing a metal cap over the bone. The procedure preserves much of the bone so that a standard hip replacement can be done years later if needed. It may provide more stability, a faster recovery, and greater range of motion, making it a potentially good option for young, physically active patients.

Revision Arthroplasty – A repair procedure called arthroplasty revision may be used in cases where the original transplant fails. The specific procedure depends on whether the bone defects that occurred are contained or uncontained.

• Contained defects can be repaired with small bone grafts, the use of cement, or oversized cementless implants as required.
• Uncontained defects are more severe and may require a large bone graft or specially constructed implants to restore bone.

If a second arthroplasty is required, the potential for complications is magnified: more bone is cut, more blood is lost, and the operation takes longer. Patients are also generally older and more vulnerable to complications.

Realigning Bones (Osteotomy)

Osteotomy is a surgical procedure used to realign bone and cartilage and reposition the joint. If only a certain section (the medial compartment) of the knee is damaged and deformed by osteoarthritis, the surgeon may choose to perform an osteotomy: