Osteoarthritis: a new approach to an old problem?
There’s been a sea change in the way the medical profession thinks about osteoarthritis, moving from the concept of joint degeneration and looking to a more holistic approach to patient care. Dr Mark Porcheret, GP and osteoarthritis specialist, explains.
Published on 12 April 2012
Wear, tear – and repair?
Osteoarthritis affects all the tissues of the joint – cartilage, bone, joint capsule, synovium (the lining of the capsule), ligaments and muscles – and is not just caused by wearing out of the cartilage. It is also not a one-way process – a condition always getting worse with time – but a process of wear followed by repair. All the tissues of the joint have the potential to repair themselves when increased cell activity leads to new tissue being produced. This does not mean that the damage to the cartilage and bone is totally reversible but that the joint, unlike a machine, is made up of living tissues which change and alter over time. The repair process is both an automatic response by the body and a process which we can actively help. For example, the body responds by producing new bone around the joint and we can help the joint to work better by strengthening muscles, getting generally fitter and, if needed, losing weight. This can result in less pain and better movement. In some people the repair is not enough to overcome the damage done to the joint and when this happens there can be ongoing pain and restricted movement. Although osteoarthritis is often referred to as ‘wear and tear’ arthritis it would be better to think about it as ‘wear and repair’ arthritis that is not a joint problem which is inevitably going to get worse but a problem which can improve and for which something that can be done.
How do we know if someone has osteoarthritis?
Traditionally, the way to tell if a joint is affected by osteoarthritis is to x-ray it. It is now recommended that an x-ray is often not necessary. It is very often possible to tell from understanding what symptoms someone is getting, examining the joint and ruling out other causes of joint problems to make a diagnosis of osteoarthritis without needing an x-ray. Typically, ongoing pain in the knee or hip in people over the age of 45 years in whom an alternative cause of the pain has been ruled out will most likely be due to osteoarthritis. However, things can change, so if your problem is worsening or you have new symptoms it is important to go back so that the diagnosis can be reviewed.
What does the future hold?
The answer is that for the individual person it can be difficult to tell, but we know that not everybody’s symptoms will get worse and that for many the symptoms can improve.
»» The pain of hand osteoarthritis often improves after a few years, though the bony lumps (the nodes) on the joints will remain.
»» The pain of knee osteoarthritis can improve and that only about a third of people with knee osteoarthritis develop severely worsening symptoms.
»» Although about a quarter of people with hip osteoarthritis find that their symptoms get worse quite quickly over a few years and they need a hip replacement, this isn’t true for all people.
What can be done?
There is no ‘magic bullet’ to cure osteoarthritis but there are many options people can use to control pain and improve movement. Many people find out what to do for themselves, but many do not and the role of GPs and healthcare professionals is to help people to better manage their condition. They can help with:
Exercise and physical activity
Getting the joint moving, strengthening the muscles and getting fitter can improve joint pain and help people to do the things they want to do.
Being overweight puts more stress on joints and that even a modest weight loss can result in better functioning of the joint.
First line painkillers
Paracetamol is still the drug to try first and at times needs to be taken at full dose and regularly, but it may not work for all and may be best not taken regularly at full strength for long periods of time.
Rub-on non-steroidal creams and gels (such as ibuprofen gel) have been shown to be as effective for knee and hand osteoarthritis as non-steroidals taken by mouth and cause fewer side-effects.
There are a large number of other treatments which have been shown to be effective in treating osteoarthritis and are recommended in the NICE osteoarthritis guidelines. There is not enough space to give individual information about them all but here is a list of some of the other treatments which are recommended to be considered: capsaicin cream, non-steroidal tablets, painkillers containing codeine and other stronger drugs, steroid joint injections, transcutaneous electrical nerve stimulation (TENS), footwear with shockabsorbing soles, shoe insoles, walking sticks, tap turners and other aids, joint supports and joint replacement. If you want to know more about any of these treatments, and whether they might be suitable for you, we suggest you ask your GP.
The information in this article was taken from a new report aimed at GPs called Osteoarthritis: a modern approach to diagnosis and management, part of a series which offers practical advice for GPs on management of musculoskeletal conditions.
This approach may be new to many GPs and healthcare practitioners and you may need to raise with them some of the approaches and treatments we have covered in this article.