This second article in a three-part series on osteoarthritis discusses pharmacological and non-pharmacological management. The third part will be published online
Osteoarthritis (OA) is a painful, progressive joint disorder that can cause stiffness, fatigue, depression and anxiety. OA management includes medical, surgical, and complementary techniques. This article discusses pharmacological management of OA, such as non-steroidal anti-inflammatory drugs and opioids, and non-pharmacological management, including weight reduction, acupuncture and joint replacement surgery. The third part of this series, to be published online, will cover the physical, psychological and social impact of OA including details about the mechanism of pain itself.
Citation: Swift A (2012) Osteoarthritis 2: pain management and treatment strategies. Nursing Times [online]; 108: 8, 25-27.
Author: Amelia Swift is a lecturer in nursing at the University of Birmingham.
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Osteoarthritis (OA) is a painful, progressive joint disorder that can cause stiffness, fatigue, depression and anxiety. Many people with the condition have difficulty in sleeping and carrying out everyday activities, and it can lead to loss of work and social isolation, reducing quality of life.
Most people who visit their GP with OA symptoms will have experienced pain and associated disability for three months or more; one in eight will be using a walking aid and 75% will have tried analgesics (Birrell et al, 2000). This shows many people with symptomatic OA try to self-manage the condition before seeking help.
OA management includes medical, surgical and complementary techniques, and every person with the condition requires an individualised treatment package.
Guidelines on the management of OA use a combination of systematic reviews and Delphi techniques to form a consensus about how the condition should be treated medically (Zhang et al, 2010; 2008; National Institute for Health and Clinical Excellence, 2008). In a systematic review, a group of experts critically appraise research evidence and retain the high- quality papers to form the guidance. The Delphi technique involves a facilitator consulting a group of experts to reduce a lengthy list of potential treatments to a mutually agreeable smaller list of the “best” available treatments.
Medications commonly used to manage OA pain include paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids.
Paracetamol is usually the first-line pharmacological treatment for managing OA pain. Although it can be as effective as NSAIDs in some people, evidence suggests paracetamol has only a modest effect in reducing pain, and no effect on stiffness or function (Zhang et al, 2008; Towheed et al, 2006). NICE guidelines recommend trying paracetamol first because, although NSAIDs provide better pain relief, paracetamol has fewer side-effects (NICE, 2008). Paracetamol is a relatively safe drug when taken at doses of less than 4,000mg per day, but it can cause gastric irritation if taken in high doses over a long period (Rahme et al, 2002).
According to NICE (2008), paracetamol and codeine combinations have no demonstrable benefit over paracetamol alone. Comparisons of paracetamol-dextropropoxyphene with NSAIDs tend to favour NSAIDs (NICE, 2008).
Non-steroidal anti-inflammatory drugs
NICE (2008) recommends using NSAIDs to manage OA pain, but they carry risks. Around 10-20% of people who use oral NSAIDs experience dyspepsia, and risk gastric complications (Wolfe et al, 1999).
The development of Cox-2 selective anti-inflammatory drugs reduced the incidence of gastric side-effects, but highlighted another problem of NSAID use - the increased risk of thrombus formation, particularly with long-term use, in older people and in those with other prothrombotic risk factors. This increases the risk of myocardial infarction and stroke (Cannon et al, 2006). NSAIDs are also associated with a slight increase in the risk of renal failure (Adam, 2011).
The risk of adverse events associated with NSAID use decreases significantly when topical gels are used instead of oral preparations. Although some people who use the gels experience dermatitis, they appear to be as effective as oral NSAIDs at controlling pain. This has led to topical NSAIDs being suggested as a first-line treatment for managing OA (Baraf et al, 2011; Zhang et al, 2010; NICE, 2008).
Opioids can be extremely effective in the management of pain. However, their benefits can be outweighed by side-effects such as nausea, vomiting, dizziness and constipation, which affect a lot of people who use these drugs (Zhang et al, 2010). A recent review that explored the use of extended-release opioids in OA found they would help to improve sleep (Turk and Cohen, 2010).
Long-term use of opioids is associated with tolerance, where sensitivity to the analgesic effects of opioids decreases over time, and hyperalgesia, where sensitivity to painful stimuli increases. Tolerance leads to a need to increase the dose of the drug, which could increase adverse effects without relieving pain. This can make clinicians reluctant to use opioids to control long-term, non-malignant pain. However, some studies suggest concerns about this are overstated, and that very few people have this problem (Schneider and Kirsh, 2010).
Patients and practitioners can be fearful about the risks of addiction with long-term opioid use. Portenoy (1990) developed criteria to identify addiction in people with chronic pain, taking into consideration the “normal” behaviours of a patient in pain that could be misconstrued as addiction; addition is diagnosed if drug-taking has persisted for at least a month and at least three of nine of the criteria are present. The criteria should be used with caution; a study by Hojsted et al (2010) found that, according to Portenoy’s criteria, almost one in five of a group of people with chronic pain were addicted to their opioid medication.
Tramadol is a synthetic analgesic that, in addition to having a morphine-like mode of action, is also a serotonin and noradrenalin reuptake inhibitor (Mongin, 2007).
This offers a theoretical advantage over other opioid preparations because it can increase the concentration of serotonin and noradrenalin in the central nervous system. Serotonin and noradrenalin are neurotransmitters that have an inhibitory action on the nervous transmission of pain.
Its side-effects include nausea, vomiting, drowsiness, constipation, dizziness and headache. In clinical trials exploring the use of tramadol for people with OA, these side-effects were mild or moderate, most often occurring during the initial titration phase rather than the maintenance phase (Langley et al, 2010). However, these adverse reactions may reduce concordance and might also lead to secondary harms such as an increase in falls.
Tricyclic antidepressants (TCAs) work by blocking the uptake of serotonin and noradrenaline from synapses in the brain and spinal cord.
These neurotransmitters are involved in inhibiting pain signals, and blocking their removal from synapses improves the body’s inhibition of pain signals. Theoretically, TCAs should be helpful in OA pain, but only one study has explored this. The study was inconclusive in terms of pain relief, but support is emerging for the benefits of TCAs in OA pain (Bellingham and Peng, 2010; NICE, 2008).
Corticosteroids or hyaluronic acid injections
Steroid or hyaluronic acid injections into the knee joints can bring partial pain relief for up to three months, and are often sought by people with OA (NICE 2008; Lambert et al, 2007).
However, there is a lack of placebo-controlled trials, and some trials suggest efficacy is limited (Avouac et al, 2007). There is also a risk of joint infection, and steroids can cause blood glucose instability in people with diabetes (Habib and Safia, 2009).
Capsaicin is a topical cream. When rubbed onto the skin, it causes the release of substance P from the C-fibre terminals. Substance P is essential in the activation of the nerve fibre because it increases the sensitivity of the nociceptor, so other chemicals can trigger an action potential. The application of capsaicin causes localised burning pain but, as it takes a while for the body to synthesise the capsaicin, the period of burning is followed by pain relief.
Using the cream twice daily often means the burning sensation does not return after the first application. A half-strength version is available for those who find it hard to tolerate the full strength preparation (Schnitzer et al, 1995).
Nutraceuticals and herbal products
Many different nutraceutical products are available, such as glucosamine, rose hip, willow bark, devil’s claw, ginger, green-lipped mussels and egg-shell membrane.
Glucosamine is one of the more popular products in the UK, but there is very little evidence that it is effective and it is not recommended by NICE (2008). US guidelines are less clear, and contain evidence of some benefit in knee pain.
There is some evidence that rose hip powder, devil’s claw and egg-shell membrane have some efficacy in pain relief, but research into these products is in the early stages (Zhang et al, 2010; Ruff et al, 2009). There is also evidence that some people benefit from eliminating certain foods from their diet, and from following specific eating plans such as a Mediterranean diet (Rayman and Pattison, 2008).
Non-pharmacological management strategies include:
- Transcutaneous electrical nerve stimulation (TENS);
- Heat or cold;
- Weight reduction;
- Joint supports;
- Walking aids;
People with OA need to maintain fitness, stamina and suppleness to facilitate confidence, independence and quality of life. Exercise can also help to alleviate pain, and fitness has a positive influence on post-operative recovery for people who have had joint replacement surgery (Pisters et al, 2010; Topp et al, 2009).
Evidence suggests aerobic exercise leads to a better outcome than strengthening exercises, which are more effective than water-based exercises (Zhang et al, 2010). Physiotherapists can give advice and support about exercise, although most people just need advice to keep fit and active.
Improvements in physical function and pain can lead to improvements in depression (Lim et al, 2005).
TENS and acupuncture
Acupuncture and transcutaneous electrical nerve stimulation (TENS) have been demonstrated to be helpful in relieving pain (Itoh et al, 2008).
Evidence suggests that, while acupuncture can be expensive, it can help to alleviate pain and stiffness, and improve function (Zhang et al, 2010).
TENS - the application of an electrical stimulus across sensory nerve pathways -stimulates the production of endorphins. This has been shown to have a positive effect on pain, and is a technique people with OA can do themselves (NICE, 2008; Zhang et al, 2008).
Heat or cold
The application of superficial heat or cold to joints can provide short-term pain relief (Denegar et al, 2010).
Heat can be applied in numerous ways, including immersion in warm water, heat packs heated at home in the microwave, heat pads and wax.
Cold is usually applied with an ice massage or by applying cold packs to the affected area.
Although there is little evidence to support the use of heat, guidelines and anecdotal evidence support it. Using a safe system is important; hot water bottles have been known to damage the skin as the temperature can be too high for direct application to skin. This is particularly important in older adults, who may have a higher pain threshold, so potential damage may not be detected as quickly as it would be in a younger person.
Obesity is a major risk factor in the development of OA, and is associated with a greater need for joint replacement surgery (Turley et al, 2006).
Weight reduction is thought to be a beneficial pain management strategy, but there is no strong evidence to support this. At present, advice to lose weight is based on expert opinion rather than conclusive randomised controlled trials or systematic reviews (Zhang et al, 2010).
Weight reduction is one of three core interventions in NICE (2008) guidance on OA management, along with information and exercise. This could be due to the overall health benefits of a normal BMI, and because obesity is a contraindication for surgery. Obesity is associated with higher anaesthetic risk, greater risk of mechanical failure of the joint replacement and a greater risk of infection after surgery (Samson et al, 2010).
Braces, sleeves and walking aids
People with OA often use walking aids, but sometimes feel embarrassed about this. Most people who use these aids do not obtain them by prescription (van der Esch et al, 2003) and this creates a potential problem of incorrect technique and sizing, which can increase risk of falls and also contribute to misalignment leading to the development of musculoskeletal pain in other places.
Use of walking aids or knee braces can help to reduce pain (Zhang et al, 2008; NICE, 2008). Knee braces are more effective than neoprene sleeves (Brouwer et al, 2005).
Replacement of the hip or knee joint can be an effective management strategy, and the number of operations continues to grow. In 2010, more than 114,000 hip and knee replacements or revisions were carried out in the UK (www.njrcentre.org.uk).
However, provision of this surgery is variable, with more operations performed in some parts of the country than others. Differences in operation rates relate to socioeconomic status, with the poorest in society undergoing the least amount of surgery (Dixon et al, 2006).
Surgery can be helpful in terms of pain reduction and restoration of function, but improvement is not guaranteed. Most people benefit from it, but around a quarter report ongoing moderate to severe pain five to eight years after surgery. Around one fifth of patients say they have not been recovered sufficient function after surgery (Jones et al, 2000).
Reasons include issues to do with the joints and prosthesis, and issues relating to the preoperative pain mechanism (Wylde et al, 2011; 2007; Kehlet et al, 2006).
Research continues to help us to understand the risk factors for persistent postoperative pain or poor function. While some aspects of pain mechanisms are not yet fully understood, and we know that patients being optimally fit is helpful, other factors remain unknown.
The management of OA involves both medical and surgical options.
People with OA often use pain-relieving medicines ad hoc, purchase walking aids and use nutraceutical products before they see their GP. Pain medications can be helpful, but none is without limitations and side-effects. Non-pharmacological solutions, such as exercise, heat, TENS, acupuncture and weight reduction can all play a part in pain management.
Nurses need to understand the complexity of pain and disability, as well as the psychological and social consequences of ongoing pain. They can then help patients decide which therapies will help relieve their pain, and improve function and quality of life.
- Osteoarthritis (OA) is a painful, progressive joint disorder that can cause stiffness, fatigue, depression and anxiety
- Paracetamol is usually the first line drug treatment for managing OA pain; it has fewer side-effects than non-steroidal anti-inflammatory drugs (NSAIDs)
- NSAIDs are associated with gastric problems, dyspepsia, thrombus formation and renal failure. Risks are lower with topical gels than oral preparations
- Obesity is a risk factor for OA and is linked to a greater need for joint replacement surgery
- More than 114,000 replacements or revisions for hip or knee joints were carried out in the UK last year
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