- OA, or degenerative joint disease, is characterized by deterioration of articular cartilage, with subsequent formation of reactive new bone at the articular surface. The joints affected most commonly are the distal and proximal interphalangeal joints of the hands, hips, knees, and cervical and lumbar spine.
- The disease is more common in the elderly but may occur at any age, especially as a sequel to joint trauma, chronic inflammatory arthritis, or congenital malformation. OA of the spine may lead to spinal stenosis (neurogenic claudication), with aching or pain in the legs or buttocks on standing or walking.
- Acetaminophen in a dosage of up to 1,000 mg up to qid is the initial pharmacologic treatment.
- Low-dose NSAIDs or selective COX-2 inhibitors are the next step, followed by full- dose treatment. However, because this patient population is often elderly and may have concomitant renal or cardiopulmonary disease, NSAIDs should be used with caution. NSAID-induced GI bleeding also is increased in the elderly population.
- Glucosamine sulfate, 1,500 mg PO daily, may reduce symptoms as well as the rate of cartilage deterioration. Intra-articular glucocorticoid injections often are beneficial but probably should not be given more than every 3-6 months.
- Systemic steroids and narcotic analgesics should be avoided, although the Âμ-opioid agonist tramadol may be useful as an alternative analgesic agent.
- Topical capsaicin may provide symptomatic relief with minimal toxicity.
- Synthetic and naturally occurring hyaluronic acid derivatives (Hyalgan, Synvisc) can be administered intra-articularly. They reduce pain and improve mobility.
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- When serious disability results from severe pain or deformity, surgery can be considered. Total hip or knee replacement usually relieves pain and increases function in selected patients.
- Laminectomy and spinal fusion should be reserved for patients who have severe disease with intractable pain or neurologic complications. Lumbar spinal stenosis may require extensive decompressive laminectomy for relief of symptoms.
- Nonpharmacologic approaches may complement drug treatment of arthritis. Activities that involve excessive use of the joint should be identified and avoided. Brief periods of rest for the involved joint can relieve pain. Poor body mechanics should be corrected and malalignments such as pronated feet may be aided by orthotics. An exercise program to prevent or correct muscle atrophy can also provide pain relief. When weight-bearing joints are affected, support in the form of a cane, crutches, or a walker can be helpful, as well as weight reduction and wearing soft-soled shoes. Consultation with occupational and physical therapists may be helpful.
- OA of the spine may cause radicular symptoms from pressure on nerve roots and often produces pain and spasm in the paraspinal soft tissues.
- Physical supports (cervical collar, lumbar corset), local heat, and exercises to strengthen cervical, paravertebral, and abdominal muscles may provide relief in some patients.
- Epidural steroid injections may reduce radicular symptoms.