Prof. Dr. Belma Füsun Köseoğlu
Faculty of Medicine, TOBB University of Economics and Technology
Department of Physical Medicine and Rehabilitation
Osteoarthritis (degenerative joint disease) is the most common chronic joint disease worldwide, lasting for more than three months. Affecting one or more joints, this disease diminishes the quality of life by causing pain, restricted movement, and disability. The most commonly affected joints are hands, knees, hips, and spine.
The point where two bones forming a joint meet is normally covered with a specialized structure called cartilage. This structure allows bones to slide over each other without causing pain, facilitating smooth movement. In osteoarthritis, the cartilage undergoes deterioration, fragmentation, and thinning. As the cartilage wears away, the bones in the joint start rubbing against each other, leading to changes in the joint’s structure and weakness in the surrounding muscles.
Several factors contribute to the development of osteoarthritis. Advanced age, female gender, obesity, genetic predisposition, repetitive stresses or loads on joints due to work or sports activities, joint injuries, and structural abnormalities in the bones can be considered among these risk factors. Age is the most potent risk factor for osteoarthritis, with the prevalence being higher in individuals over the age of 45. For instance, knee osteoarthritis is the most common cause of lower extremity (leg) disability in people worldwide aged 50 and older.
This disease has a subtle onset, progressing slowly over the years, gradually intensifying and worsening over time, leading to symptoms such as pain in the spine, knees, hips, and hands, stiffness lasting less than half an hour in the mornings, joint tenderness, swelling, noises during movements, and a decrease or loss of movement function in the spine, knees, hips, and hands. Initially, there are pains that increase with movement (such as walking, climbing up and down stairs, stepping after prolonged sitting, using hands for gripping or squeezing, squatting and standing up), and decrease with rest. As the disease progresses, the pains become constant, and nighttime and rest pain are added to the disease symptoms. Prolonged painful conditions can be accompanied by depression and sleep disorders. Osteoarthritis does not cause inflammation (swelling) in the joints, and symptoms such as changes in joint color and increased temperature are not present.
The diagnosis of this disease is generally based on the patient’s history and examination. Radiological evaluation may be required to rule out other diseases. Blood tests are not routinely necessary but may be ordered to rule out other diseases. For example, in a person over 50 years old, a diagnosis of knee osteoarthritis can usually be made with complaints such as pain in the knee joint when bearing weight and moving, morning stiffness lasting less than 30 minutes, sounds coming from the knee when going up and down stairs, and bony enlargements and deformities in the knee, and additional tests are usually not necessary.
The Goals of Treatment in Osteoarthritis: controlling pain, preserving and improving joint functions, maintaining muscle strength, preventing/improving disability, and enhancing the quality of life.
NON-PHARMACOLOGICAL TREATMENTS: These treatments are an essential part of osteoarthritis therapy and are recommended for all patients. Non-drug treatments can improve disease-related symptoms, have minimal side effects, and are generally the first-line treatments recommended by physicians.
- Patient education: Informing the patient about reducing the load on the joint during activities, activities to be avoided, the importance of balancing physical activity and rest, treatment options, advantages and disadvantages of treatment options, the impact of the disease on daily life activities, coping methods for disease progression (prognosis), and restrictions caused by the disease. Education positively affects treatment outcomes and is therefore strongly recommended in osteoarthritis therapy.
- Weight loss: Being obese or overweight is a significant risk factor for the development of hip and knee osteoarthritis, and weight loss has been shown to be effective in reducing pain and improving function in this disease. Weight loss in hip and knee osteoarthritis is strongly recommended in osteoarthritis therapy.
- Physical therapy applications and exercise: These treatments increase flexibility and reduce pain by strengthening the muscles around the joint, as shown to be effective in reducing pain and increasing function. Applications such as temperature treatments (cold and heat), paraffin, acupuncture, kinesiotaping (bandaging) can be conditionally tried. The effectiveness of laser, massage, therapeutic ultrasound, vibration therapy, electric current, iontophoresis, and manual therapy applications requires more scientific research and can be conditionally tried. Exercise is strongly recommended in the treatment of hand, knee, and hip osteoarthritis. In addition to classical exercises such as joint range of motion, strengthening, endurance, and flexibility exercises, mind-body exercises such as tai chi and yoga, as well as balance exercises, are recommended in osteoarthritis therapy. Water exercises are especially recommended for osteoarthritis patients with widespread pain and depression.
- Orthoses (braces-splints): The use of special devices externally attached to the body in hand and knee osteoarthritis shifts some of the forces acting on the affected part, reducing pain and assisting in maintaining joint function. Braces and thumb orthoses are strongly recommended in the treatment of knee and thumb osteoarthritis. However, there is no clear evidence that orthopedic shoes, orthopedic insoles, and shoe modifications are effective in treating this disease, and more scientific research is needed.
- Assistive devices: Daily functional aids such as canes, walkers, toilet risers, and shower bars reduce the load on the joints, relieve pain, and assist in function. The use of a cane is strongly recommended in the treatment of knee and hip osteoarthritis.
- Cognitive-behavioral therapies: Recommended in osteoarthritis patients with widespread pain and depression.
DRUG TREATMENTS: These treatments can be initiated with or following non-drug treatments mentioned above.
- Topically applied drugs to the joint:
They reduce pain in hand and knee osteoarthritis. For this purpose, non-steroidal anti-inflammatory drugs (creams, gels, etc.) without steroids can be used. Topically applied drugs for painful joints are strongly recommended in knee osteoarthritis.
- Nonsteroidal anti-inflammatory drugs (NSAIDs):
These drugs relieve pain, reduce inflammation, and are the mainstay of drug treatment in osteoarthritis. There are many different drugs in this class. They are used at the lowest effective dose and for a short duration to minimize side effects. These drugs are strongly recommended in the treatment of hand, knee, and hip osteoarthritis.
This drug has a limited effect on reducing pain, and it can have side effects, especially on the liver. Therefore, it can be used for a short duration and intermittently in patients who cannot use non-steroidal anti-inflammatory drugs for various reasons.
- Other drugs:
Duloxetine can be used in patients with widespread pain and depression in osteoarthritis, either alone or in combination with nonsteroidal anti-inflammatory drugs, due to its analgesic effect. The use of tramadol and other opioids (morphine-like drugs) is limited in osteoarthritis because of the high side effects and the risk of dependence with long