Rehabilitation for Osteoarthritis

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Overview of Osteoarthritis Rehabilitation

Osteoarthritis (OA) is a chronic disease process affecting synovial joints, particularly large weight-bearing joints. OA is particularly common in older patients but can occur in younger patients either through a genetic mechanism or, more commonly, because of previous joint trauma. (See the images below.)



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This radiograph demonstrates osteoarthritis of the right hip, including the finding of sclerosis at the superior aspect of the acetabulum. Frequently,....



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This radiograph demonstrates osteoarthritis of bilateral knees. Radiographic findings of osteoarthritis are often graded using the Kellgren-Lawrence G....

OA rehabilitation is aimed at bringing about pain reduction, function optimization, and the advantageous modification of the joint damage process.[1]  To help achieve these goals, the overall rehabilitation strategy for patients with OA can include various components, including the following[2] :

For other discussions on OA, see Osteoarthritis, Wrist Arthritis, Surgical Treatment of Patellofemoral Arthritis, and Glenohumeral Arthritis, as well as Injection of the Acromioclavicular Joint, Total Knee Arthroplasty, Unicompartmental Knee Arthroplasty, Shoulder Arthrocentesis, Surgical Treatment of Interphalangeal Joint Arthritis, Medial Compartment Arthritis, Surgical Treatment of Lateral Compartment Arthritis, Imaging of Osteoarthritis, and Progression of Osteoarthritis.

Therapeutic Exercise for Osteoarthritis

General principles

Lifestyle modification, particularly exercise and weight reduction, is a core component of the management of OA,[3, 4, 5]  with the aim of such efforts being provision of pain relief, enhancement of physical function, and improvement of quality of life. Therapeutic exercise programs have been shown to be a successful nonpharmacologic method of achieving these goals. Among the wide range of existing OA exercise programs, stress is placed on various types of exercises; exercise intensity, duration, and supervision; and different types of resistance equipment.[6]

Mechanism of action of therapeutic exercise

The 2017 Ottawa Panel guidelines for the management of knee OA describe the physiologic effects of therapeutic exercise. Resistance exercise, resulting in antinociception via endogenous analgesia, may relieve osteoarthritic pain.[6] A literature review by Runhaar et al indicated that the mechanisms by which exercise reduces pain and improves function in cases of OA may include the development of increased upper leg strength, the reduction of extension impairments, and the improvement of proprioception. The review involved 94 studies, most of which assessed patients with OA only in the knee.[7]

Types of exercise programs

Therapeutic exercise programs can include resistance, functional, or mixed (resistance, balance, coordination) exercises, with muscle-strengthening strategies encompassing the following categories[6] :

A systematic review and meta-regression analysis by Juhl et al found that optimal therapeutic exercise programs focus on a single type of exercise, such as aerobic or muscle strengthening (of the quadriceps). The notion that it is preferable to perform either aerobic or resistance exercise, rather than both types, in a single session is related to the molecular response to exercise. The molecular response to resistance training involves an increase in myofibril proteins, whereas in aerobic training, mitochondrial activity is increased. When an individual performs aerobic and resistance exercises within the same session, the molecular response to both appears to decrease. The study also found that for best results in pain reduction, the exercise program should be supervised and consist of three sessions per week.[8]

Most research focuses on quadriceps strengthening in knee OA. Also important are stretching exercises, which increase range of motion. The importance of aerobic conditioning, particularly low-impact exercises (if OA affects weight-bearing joints), should be stressed. Swimming, especially aerobic aquatic programs through the Arthritis Foundation, can be helpful. Certain studies also indicate that a home exercise program for patients with OA of the knee provides an important benefit.[7]

A study by Farrokhi et al of patients with unilateral, symptomatic knee OA found that walking exercise of 30 continuous minutes or more may result in undesirable knee joint loading and increased pain, while the same amount of exercise broken into separate intervals with rest periods in between may produce no pain increase. Patients in the study underwent two different exercise sessions, including one continuous 45-minute walk on a treadmill and three 15-minute treadmill walks separated by hour-long rest periods.[9]

In a study of patients with knee OA, Jan et al found that, in most respects, non–weight-bearing exercise was as therapeutically effective as weight-bearing exercise.[10]  After an 8-week program, weight-bearing and non–weight-bearing exercise produced equally significant improvements in function, walking speed, and muscle torque. However, patients in the weight-bearing group demonstrated greater improvement in position sense, which may help with complex walking tasks, such as walking on a spongy surface.

A systematic review by Fransen et al found that land-based exercises reduced pain and improved physical function in patients with knee OA. Furthermore, the study determined that there was no difference in outcomes between weight-bearing and non–weight-bearing exercises that targeted the quadriceps. There was also no difference found between quadriceps exercises that were performed eccentrically/concentrically versus those that were performed isometrically.[11]

Chaipinyo and Karoonsupcharoen found no significant difference in the reduction of OA-related knee pain between home-based strength training and home-based balance training.[12]  However, more improvement in knee-related quality of life was noted in the strength-training group than in the balance-training group.

Results from a study by Wang et al suggested that tai chi is a potentially effective treatment for pain associated with OA of the knee.[13]  In a prospective, single-blind, randomized, controlled trial, 40 patients with symptomatic tibiofemoral OA who performed 60 minutes of tai chi twice weekly for 12 weeks experienced significantly greater pain reduction than did control subjects who underwent 12 weeks of wellness education and stretching. The tai chi cohort also had significantly better Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function scores, patient and physician global visual analog scale scores, chair stand time, Center for Epidemiologic Studies Depression Scale scores, self-efficacy scores, and Short Form 36 physical component summaries.

Another study, a meta-analysis by Chang et al, found that an 8- to 24-week program of tai chi improves quadriceps muscle strength in knee OA, allowing elderly patients to prevent or reduce deterioration and loss of daily function. Furthermore, the study indicated that a program consisting of 10 movements of tai chi is ideal for these patients, since it appears that the geriatric population would be less compliant with the program if more than 10 movements were involved.[14]

However, unlike for knee or hip OA, there is no clear consensus on the benefits of exercise therapy for hand OA in terms of pain reduction and function improvement. A review by Magni et al looking at the potential benefits of resistance training for hand OA found no evidence supporting resistance training for function improvement and reported that there was a clinically insignificant benefit in pain reduction.[15]  Another review study of hand OA, by Østerås et al, found only mild benefit in terms of pain reduction and function improvement. Both reports agreed that the lack of consensus on the efficacy of exercise therapy in hand OA is due to the relatively limited amount of research on the subject.[16]

Home exercise programs versus formal physical therapy

There is conflicting evidence with regard to the benefits of supervised versus nonsupervised exercise programs.[17]   A randomized, controlled study by Kuru Çolak et al found that in knee OA, supervised exercises were more effective at reducing pain and increasing quadriceps and hamstring strength than were nonsupervised exercises. The report determined that the best therapeutic results were derived from low-intensity exercises, due to the ease with which geriatric patients could perform them, and from performance of the exercises at least three times a week. The study also found that the total program should be composed of at least 12 sessions. The investigators noted that although a previous study acknowledged that both supervised and nonsupervised exercises would reduce pain from knee OA, the degree of pain relief was not assessed.[18]

A systematic review by Brosseau et al reported that in 10 high-quality studies of therapeutic exercise programs with a home-based/nonsupervised component, at least one program goal was reached. In contrast, the same results were found in 19 studies of programs with a clinic-based or supervised-session component.[6]

Exercise compliance

A literature review by Marks and Allegrante indicated that in order to encourage people with OA to adhere to an exercise regimen, “interventions to enhance self-efficacy, social support, and skills in long-term monitoring of progress are necessary."[19]

Occupational Therapy for Osteoarthritis

Occupational therapy for OA aims to improve quality of life by modifying the environment to maximize the function of affected joints. Although there are different ways to accomplishes this, two common methods are the use of assistive devices and joint protection. Assistive devices, such as spoons with a large grip/handle, alleviate joint strain and improve function. Joint protection involves means of reducing the use of and strain on affected joints, such as by cradling objects with two arms rather than holding them with the affected joint/limb.

Two common types of nonspecific assistive devices are prefabricated neoprene splints and custom-made thermoplastic splints.  However, although assistive devices may be an effective alternative to other nonpharmacologic treatments with regard to reducing pain and improving quality of life, research is lacking on the effectiveness of splint use.[20] .

Although quality of life may be improved by occupational therapy alone, the use of multiple concurrent therapeutic regimens seem to have a greater impact than does single-modality therapy.[21]

Medication for Osteoarthritis

The American College of Rheumatology (ACR) 2012 pharmacologic guidelines for the treatment of hip and knee OA include the following[22] :  

The following ACR recommendations apply to patients with a history of symptomatic or complicated upper gastrointestinal (GI) bleed:

For hand OA, the ACR 2012 guidelines recommend topical or oral NSAIDs, topical capsaicin, and tramadol as options for pharmacotherapy.[22]

In a randomized, controlled study by Petersen et al of patients with knee OA, neither ibuprofen nor glucosamine improved muscle mass gain during a 12-week strength-training program. However, patients on these medications achieved improved maximal muscle strength gain in comparison with patients on placebo treatment, but the benefits were not significant enough to advocate taking NSAIDs or glucosamine.[23]

Disease-modifying therapies that may slow or reverse joint structural destruction in OA are under investigation. Glucosamine and chondroitin sulfate are in current use due to their demonstrated association with chondrocyte anabolism and catabolism[24] .  A 2011 review by the Agency for Healthcare Research and Quality found that in knee OA, chondroitin sulfate shows medium-term benefits, but no long-term benefits, either individually (on pain alone) or in combination with glucosamine (on pain and function).[25]  Therapies targeting the inflammation processes (ie, interleukin-1β [IL-1β] and tumor necrosis factor-ɑ [TNF-ɑ] inhibitors, granulocyte-macrophage colony-stimulating factor [GM-CSF] antibody) and subchondral bone remodeling (ie, bisphosphonates, calcitonin) are also being investigated.[24]

In a randomized, double-blind, multicenter study, etodolac plus acetaminophen was significantly more effective than etodolac alone for osteoarthritic flare-ups. Measurements of reduced pain intensity, achievement of pain relief, and symptom resolution (eg, decreased morning stiffness, inflammation) showed significantly greater improvement with the combination compared with etodolac by itself.[26]

Intra-Articular Injections

Steroid injections

Intra-articular steroid injections may provide pain relief and have an anti-inflammatory effect on osteoarthritic joints. Such injections are generally believed to result in a clinically and statistically significant reduction in osteoarthritic knee pain, often beginning as soon as a couple of days after injection. The effect may last, on average, anywhere from 4-6 weeks per injection, but this benefit is unlikely to continue beyond that time frame.[27]  One randomized, placebo-controlled study confirmed the effectiveness of corticosteroid injection in the treatment of osteoarthritic hip pain, with benefits often lasting up to 3 months.[28]

An extended-release intra-articular therapy option, Zilretta (triamcinolone acetonide), was approved by the US Food and Drug Administration (FDA) in October 2017 to manage osteoarthritic knee pain. Phase 3 trial results published in April 2018 found that Zilretta provided approximately 50% reduction in pain from baseline over weeks 1 through 12, with benefit occurring as late as week 18. Zilretta was also found to improve stiffness and function. The most commonly reported side effects were joint pain, headache, and back pain.[29]

However, there is also some evidence of detrimental effects from corticosteroid injections. For example, in a randomized clinical trial of knee OA patients, those who received intra-articular triamcinolone injections over 2 years, compared with intra-articular saline over the same period of time, had significantly greater cartilage volume loss but no significant difference in knee pain. Such treatment for patients with symptomatic knee OA is not supported by these findings.[30]

Viscosupplementation

Intra-articular injection of sodium hyaluronate (i.e., hyaluronic acid [HA], hyaluronan), also referred to as viscosupplementation, has been available in the United States since 1997. The largest meta-analysis of intra-articular HA injection, involving 76 controlled clinical studies (and subsequently updated by the Cochrane Collaboration), concluded that this therapy is safe and effective in patients with knee OA.[31]

The FDA has approved multiple intra-articular HAs for the treatment of pain associated with knee OA. These include naturally extracted, non–cross-linked products, chemically cross-linked agents, and bacterially fermented viscosupplements. Although some of these agents differ with respect to molecular weight, molecular weight per se has not been found to correlate with efficacy. Interestingly, the duration of residence of an intra-articular injection (days) cannot explain the prolonged clinical benefit (months), and accordingly, biologic mechanisms have been proposed that may play an important role in HA's efficacy.

Generally, the safety profile of the HA class has been shown to be very favorable for osteoarthritic knee pain management. Injection-site pain is the most frequent adverse event. Severe acute inflammatory reaction [SAIR], or HA-associated intra-articular pseudosepsis, is a clinically distinct side effect related to the cross-linked hylan G-F 20 product. An immunologic mechanism of action may be the cause.[32]

In the United States, HAs are classified as medical devices rather than medications. Although the exact mechanisms of action through which they provide symptomatic relief are unknown, several possibilities exist, including direct binding to receptors (CD44 in particular) in the synovium and cartilage that can lead to several biologic activation pathways. Other possible mechanisms of action include the increased endogenous production of hyaluronate and aggrecan by the joint, a mechanical barrier to the activation of nociceptors, the inhibition of pain mediators (eg, prostaglandin E [PGE], bradykinin), an anti-inflammatory effect (eg, inhibition of proinflammatory cytokine activity, inhibition of inflammatory cell function), a beneficial effect on immune cells, an antioxidant effect, and the restoration of the synovial fluid's physical characteristics (viscoelasticity). Viscosity can help to facilitate the cushioning and lubricating characteristics of the joint during slow movements, while elasticity blunts deforming forces (compression and resistance to shear forces) during rapid motions. A study by Waddell and colleagues hypothesized that hyaluronan inhibits IL-1β–induced metalloproteinase production from osteoarthritic synovial tissue.[33]

Intra-articular HAs may possibly be chondroprotective especially in early OA. As reviewed by Goldberg and Buckwalter, preclinical support is available for most of the HAs, as well as clinical evidence (particularly for Hyalgan) using arthroscopy, microscopy, and blinded morphologic assessments and weight-bearing radiographs for assessing joint space narrowing.[34] However, additional studies are warranted to further explore the ability of HAs to intervene in the disease processes associated with OA. Certainly, a single product with symptomatic and disease-modifying characteristics, even if only in some patient populations, would be a valuable option in the management of knee OA.

There is some data on the effectiveness of HA injections with respect to OA severity. Specifically, these injections were found to be most beneficial in earlier grades of knee OA; following infection, 91% and 80% of patients with radiographic grade I and II knee OA, respectively, reported improvement in their condition, as did 76% and 58% of patients with grades III and IV, respectively. HA injections may help to delay the need for total knee arthroplasty (TKA). According to 2015 data published by the Osteoarthritis Research Society International, treatment with HA injections can delay the need for TKA by up to 3.6 years.[35]

Studies have found HA injections to be a cost-effective treatment in comparison with conventional care modalities, such as analgesics, corticosteroids, NSAIDs, assistive devices, and TKA. Moreover, while HA injections have been reported to be as effective as corticosteroid injections in the short-term, evidence indicates that HA injections provide longer duration of pain relief. In addition, owing to the risks of weight gain and hyperglycemia associated with corticosteroids, HA injections may be a better alternative for patients with comorbidities, particularly obesity and diabetes.[35]  Quadriceps strengthening combined with HAs may synergistically affect pain.[32]

Ultrasonographically guided HA injections can enhance accuracy and improve patient-reported clinical outcomes and cost-effectiveness.[35]

Platelet-rich plasma (PRP) injections

PRP injections are becoming more commonly performed as a treatment option for patients with OA. PRP, which is derived from the patient’s own blood, delivers a concentration of growth factors to the site of pathology. In a randomized, controlled trial on knee OA patients conducted by Spaková et al, it was found that patients had decreased pain and stiffness and improved physical function at 3 and 6 months after the injection.[36]

A study that compared the efficacy of PRP and HA intra-articular injections for primary knee OA found that although at 3- and 6-month follow-up, all outcome measures improved in association with both treatments, the PRP group achieved significantly better results. Synovial hypertrophy and vascularity scores improved and, in comparison with patients who underwent HA injections, effusion was lower, in patients treated with PRP injections.[37]

By enhancing the expression of NF-kappa-beta inhibitor, resulting in a decrease in nuclear factor-κβ (NF-κβ) signaling and a dampening of its downstream inflammatory cytokine activation, PRP can reduce osteoarthritic joint inflammation. PRP is capable of switching off type II collagen inhibition and aggrecan gene expression in IL-1β–activated NF-κβ in chondrocytes. Thus far, PRP has been mainly employed in the treatment of musculoskeletal conditions, especially tendon-related pathologies.[38, 39]

Biologic injections

Biologics (protein-derived medications from cultured cells) have also been explored in the treatment of OA, especially in patients whose condition was refractory to conventional drugs. In a 12-month pilot study on erosive hand OA, monthly intra-articular injections of infliximab (a monoclonal antibody against TNF-ɑ) into the affected joints was found to cause a reduction in anatomic lesions when compared with joints injected with saline.[40]

Stem cell therapies

A therapeutic case series study published in 2015 found that adipose stem/stromal cell (ASC) and stromal vascular fraction (SVF) procedures improved symptom‐related, functional, radiographic, and histologic scores in patients with OA. Patients recruited into the study were usually refractory to oral medications, physical therapy, autologous cartilage transplantation, and HA injection. Patient questionnaires indicated that administration of SVF or ASCs into affected joints led to improvements in pain, function, mobility, and overall quality of life. Evidence for the effectiveness of SVF or ASC administration also emerged from evaluation with magnetic resonance imaging (MRI) and arthroscopy, with improvement or maintenance of cartilage status found. Patients in these studies experienced clinical improvement over a period of between several months and more than 2 years.[41]

Preclinical studies indicate that ASCs exercise their effects via an ASC-mediated decrease in pro‐inflammatory cytokines and chemokines, apoptosis of chondrocytes, hypertrophic and fibrotic chondrocyte phenotypes, and collagenases. Multiple phase-1 clinical trials have indicated that SVF-cell and ASC administration is safe. As evidenced in six studies (130 patients), joint pain is the most frequent adverse event. Neither liposuction nor intra-articular injection of stem cells was associated with adverse events. These results suggest that in patients with severe, treatment-refractory OA, especially that involving the knee, SVF cells and ASC are therapeutic candidates.[41]

Other Treatments

Orthoses

Although orthotic devices are widely used for OA, there is limited supporting evidence that such devices are beneficial.

Footwear interventions, such as cushioning, appear to reduce pain and increase function, and reduce plantar pressure in people with first metatarsophalangeal (MTP) OA.[42]  A 12-month study of 200 people aged 50 years or older with medial knee OA found no symptomatic or structural differences between patients who wore lateral wedge insoles and those who wore flat control insoles, inside their footwear[43] .

Since 2015, a device known as the Unloader Hip brace has been available in the United States for use in patients with symptomatic hip OA. This brace was derived in part from the WISH-type modified S-form hip brace from Japan. The current Unloader Hip brace likely exerts its overall effect via several mechanisms, with the brace featuring a trochanteric pad that provides direct compression, thus helping with proprioceptive support of the hip joint, and a dynamic rotation strap that shifts compressive forces away from the main osteoarthritic region in the superior-lateral corner of the joint (via external rotation and abduction). The overall brace also improves joint stability. Supporting evidence for the Unloader Hip brace's efficacy includes a gait analysis study of 14 subjects with unilateral hip OA. The report found that use of the brace led to a significant reduction in peak internal hip abduction force (the major factor indicative of hip joint loading during the single support phase of gait) and a significant decrease in ambulation pain.[44]

A review study that included six randomized, controlled trials and five nonrandomized, controlled trials concluded that soft braces appear to provide moderate pain relief and improve functionality in knee OA, which may play an important role in short-term and long-term OA management.[45]

However, although many clinical trials involving orthotic interventions have been performed, there has not yet been enough high-quality research to provide strong evidence for the benefit of orthotic devices.[46]

Nonetheless, people with OA may receive limited benefit from use of orthotic devices. Patients and physicians should discuss risks and benefits on individual basis to provide optimal outcome.

Acupuncture

Acupuncture is becoming a more frequently utilized option in treating pain and physical dysfunction associated with OA. There appears to be a subjective benefit from acupuncture for the treatment for osteoarthritic pain, but no conclusive evidence can be drawn due to an insufficient amount of supporting evidence.[47, 48]

Massage therapy

Massage therapy is another alternative to improve symptoms of OA. Some research into the effects of massage therapy has shown positive results, with, for example, patients in a randomized, controlled trial of 125 adults with knee OA reporting improvements in pain and function in conjunction with 8 weeks of massage therapy.[49]

Moreover, in small-group studies performed in 2014 and 2017, patients reported increased activities of daily living after massage therapy.[50, 51]

Currently, however, not enough data are available to conclusively support massage therapy as having clinically significant therapeutic value in OA. Further research and study are required to determine its benefit.

Transcutaneous electrical nerve stimulation (TENS)

TENS may be another treatment option for pain relief. To date, however, there are conflicting study results regarding its efficacy.

Some studies support the use of TENS. Analysis of 3-month use of TENS in 23 people with OA of the knee found a reduction in the Visual Analog Scale score, implying subjective reduction of pain and improvement in function and quality of life.[52] One randomized controlled trial looked at the effects of TENS with home exercise in 60 patients with Kellgren-Lawrence grade 3 or 4 knee OA. Analysis at the 10-week and 6-month mark showed subjective improvement in pain and function.[53]  (See the images below.) Another study evaluated the use of TENS with and without heat and cold packs on knee OA, with patients reporting subjective immediate pain relief, as well improvement in ambulation, gait, and balance; however, the long-term effects were unclear.[54]



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Osteoarthritis of the knee, Kellgren-Lawrence grade 3.



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Osteoarthritis of the bilateral knees, Kellgren-Lawrence grade 2.

There are also studies indicating that TENS is not effective. Patients referred for physiotherapy for knee OA involved in a randomized, sham-controlled clinical trial by Palmer et al reported no significant improvement after use of TENS.[55] Another study, which examined the use of TENS after TKA, concluded that no significant difference existed between TENS and non-TENS patients with regard to postsurgical opioid usage and other endpoints.[56]

The conflicting results from these studies suggest the needs for larger and higher-quality randomized, controlled trials.

Pulsed electromagnetic field (PEMF) stimulation

A PEMF-stimulation device (Bionicare) has been FDA-approved for use in patients with knee OA. PEMF stimulation is believed to act at the level of hyaline cartilage by maintaining proteoglycan composition of chondrocytes via down-regulation of composition turnover.[57]  PEMF stimulation has also been shown to induce an anti-inflammatory mechanism through gene expression on the cellular and tissue levels.

A multicenter, double-blind, randomized, placebo-controlled, 4-week trial in 78 patients with knee OA found improved pain and function in patients who were treated with the PEMF-stimulation device.[58] Another, small study, of patients with cervical OA, found that the PEMF-stimulation group showed improvement in active range of motion and paravertebral muscle spasm and in the Neck Pain and Disability Scale, compared with the sham group.[59]  (See the image below.)



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Osteoarthritis of the cervical spine, anteroposterior view.

However, other research has found a lack of evidence to support the use of PEMF stimulation. A literature review identified five randomized, controlled trials from between 1966 and 2005 on the use of PEMF stimulation. The analysis revealed no clear evidence that the modality provides significant pain relief in knee OA.[60] A clinical trial involving 459 osteoarthritic subjects reported that although PEMF stimulation did not reduce pain, it did improve function.[61]

Consequently, while PEMF stimulation may provide some pain relief to people with OA, it is still unclear whether it provides any therapeutic value. This option may be considered after unsuccessful results from other conventional and alternative treatment methods.

Surgical Intervention

Surgical intervention for OA may be indicated. Types of procedures vary according to the site and the degree of involvement.

Surgical interventions for OA of the knee include the following:

Surgical interventions for OA of the hip include the following:

For the knee, unicompartmental arthroplasty can serve as an alternative to TKA, particularly when the OA is primarily unicompartmental. Improved surgical techniques and implants have led to more frequent use of this option, with recovery from the operation tending to be faster and the resulting range of motion better than those associated with TKA.[63]

Hip replacements generally are classified as either hemiarthroplasty (ie, replacement of the femoral side of the hip joint, while leaving the patient's acetabulum intact) or total hip arthroplasty (replacement of the femoral side of the hip joint and the acetabulum).

Further classification often involves specification of the hardware used (eg, unipolar prosthesis, bipolar prosthesis) and whether or not cement is used to hold the hardware in place.

The prognosis is good for patients with OA who have undergone joint replacement. According to a meta-analysis by Vissers et al, patients who undergo hip replacement can return to as much as 80% of normal daily activity around 6 months after surgery.[64] The prosthesis may need revision 10-15 years after its installation, depending on the patient's activity level.

Consultations

Consultation with an orthopedic surgeon may sometimes be needed. Rheumatology consultation is indicated if an alternative diagnosis (eg, rheumatoid arthritis) is suggested.

Deterrence and Prevention

The overall topic of OA prevention is lacking in significant research evidence. The following factors have been examined to different degrees.

Body mass index (BMI)

The relationship of BMI to OA has been explored in some detail. For example, it is believed that maintaining ideal body weight lessens the probability of developing OA. This appears to be particularly true for weight-bearing joints (ie, hips, knees) in women. A cross-sectional, retrospective analysis concluded that individuals with a higher risk for worse knee OA symptoms include women and persons with a higher BMI.[65] According to Messier et al, even a 10% weight loss in overweight and obese patients could improve knee OA by decreasing weight loads during walking. [66]

Therapeutic exercise

Although various studies have found that physical activity improves function in adults with arthritis, it is unclear if this translates into a decreased likelihood of OA development and progression.[67]

Vitamin supplementation

It was formerly believed that adequate vitamin D intake can lessen the risk of developing OA. However, a 2018 study by Cakar et al found no statistically significant association between serum vitamin D concentrations and osteoarthritic knee pain.[68] Nonetheless, additional studies are needed to conclusively determine the role of vitamin D in OA pathophysiology and pain perceptions. In contrast to the lack of association of vitamin D levels with knee OA pain, limited evidence suggests that in patients with late-stage knee OA, improvement in clinical symptoms and a decrease in oxidative stress conditions can be achieved via vitamin E's antioxidant properties.[69]

Surgical intervention

Meniscus-preserving techniques rather than partial meniscectomy can in the long-term help to prevent the development of knee OA.[70]

Patient Education

As the prevalence of OA increases, more patients are dealing with chronic osteoarthritic pain. A systematic review by Ali et al showed that patient education and psychosocial support play a critical role improving outcomes of patients with OA and their adherence to treatment.[71] Patient education is one of the primary therapeutic approaches to OA.[72] Several Arthritis Foundation studies have demonstrated that education in OA benefits the patient. Through education, patients can institute ways to reduce pain and increase joint function. It is important for the clinician to emphasize the need for physician follow-up visits.

For patient education information, see the Arthritis Center and Osteoarthritis, as well as the Arthritis Foundation.

 

Author

Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation, Director, Outpatient Occupational/Musculoskeletal Medicine, Rutgers New Jersey Medical School

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Ossur, Fidia.

Coauthor(s)

Alex John, MD, Pre-Intern, Department of Physical Medicine and Rehabilitation, University Pain Medicine and Rehabilitation Center, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Jaya S Sanapati, MD, Medical Scribe, Department of Physical Medicine and Rehabilitation, University Physician Associates, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Kevin Y Zheng, MD, Pre-Intern, Department of Physical Medicine and Rehabilitation, University Pain Medicine and Rehabilitation Center, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Laxminarayan Prabhakar, MD, Pre-Intern, Department of Physical Medicine and Rehabilitation, University Pain Medicine and Rehabilitation Center, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Max Snow, MD,

Disclosure: Nothing to disclose.

Patrick M Foye, MD, Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA, Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Disclosure: Nothing to disclose.

Additional Contributors

Curtis W Slipman, MD, Director, University of Pennsylvania Spine Center; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center

Disclosure: Nothing to disclose.

Hossam Edwin Hanna, MS, Rowan University School of Osteopathic Medicine

Disclosure: Nothing to disclose.

Jenoj S Gnana, MD, Pre-Intern, University Pain Medicine and Rehabilitation Center, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Nourma Sajid, MD, Syosset Endocrinology and Cardiology

Disclosure: Nothing to disclose.

Patrick J Bachoura, MD, Pre-Intern, Coccyx Pain Center (Tailbone Pain Center), Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Raj Desai, MD, Resident Physician, Department of Physical Medicine and Rehabilitation, Marianjoy Rehabilitation Center, Chicago Medical School at Rosalind Franklin University of Medicine and Science

Disclosure: Nothing to disclose.

Vivan Shah, MD, Resident Physician, Department of Physical Medicine and Rehabilitation, Beaumont Hospital, Taylor

Disclosure: Nothing to disclose.

Acknowledgements

Irim Ciolino, MD Resident Physician, Department of Physical Medicine and Rehabilitation, Georgetown University Hospital-NRH

Disclosure: Nothing to disclose.

Leia Rispoli Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Dev Sinha, MD Resident Physician, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Health Systems

Disclosure: Nothing to disclose.

References

  1. Deveza LA. Overview of the management of osteoarthritis. UpToDate. Updated 2017 Oct 11.
  2. Abbate LM, Jeffreys AS, Coffman CJ, et al. Demographic and Clinical Factors Associated With Nonsurgical Osteoarthritis Treatment Among Patients in Outpatient Clinics. Arthritis Care Res (Hoboken). 2018 Aug. 70 (8):1141-9. [View Abstract]
  3. Roddy E, Doherty M. Changing life-styles and osteoarthritis: what is the evidence?. Best Pract Res Clin Rheumatol. 2006 Feb. 20(1):81-97. [View Abstract]
  4. Perrot S, Poiraudeau S, Kabir M, Bertin P, Sichere P, Serrie A, et al. Active or passive pain coping strategies in hip and knee osteoarthritis? Results of a national survey of 4,719 patients in a primary care setting. Arthritis Rheum. 2008 Nov 15. 59(11):1555-62. [View Abstract]
  5. Bijlsma JW, Dekker J. A step forward for exercise in the management of osteoarthritis. Rheumatology (Oxford). 2005 Jan. 44(1):5-6. [View Abstract]
  6. Brosseau L, Taki J, Desjardins B, et al. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs. Clin Rehabil. 2017 May. 31 (5):596-611. [View Abstract]
  7. Runhaar J, Luijsterburg P, Dekker J, et al. Identifying potential working mechanisms behind the positive effects of exercise therapy on pain and function in osteoarthritis; a systematic review. Osteoarthritis Cartilage. 2015 Apr 9. [View Abstract]
  8. Juhl C, Christensen R, Roos EM, Zhang W, Lund H. Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. Arthritis Rheumatol. 2014 Mar. 66 (3):622-36. [View Abstract]
  9. Farrokhi S, Jayabalan P, Gustafson JA, Klatt BA, Sowa GA, Piva SR. The influence of continuous versus interval walking exercise on knee joint loading and pain in patients with knee osteoarthritis. Gait Posture. 2017 May 17. 56:129-33. [View Abstract]
  10. Jan MH, Lin CH, Lin YF, Lin JJ, Lin DH. Effects of weight-bearing versus nonweight-bearing exercise on function, walking speed, and position sense in participants with knee osteoarthritis: a randomized controlled trial. Arch Phys Med Rehabil. 2009 Jun. 90(6):897-904. [View Abstract]
  11. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee: a Cochrane systematic review. Br J Sports Med. 2015 Dec. 49 (24):1554-7. [View Abstract]
  12. Chaipinyo K, Karoonsupcharoen O. No difference between home-based strength training and home-based balance training on pain in patients with knee osteoarthritis: a randomised trial. Aust J Physiother. 2009. 55(1):25-30. [View Abstract]
  13. Wang C, Schmid CH, Hibberd PL, Kalish R, Roubenoff R, Rones R, et al. Tai Chi is effective in treating knee osteoarthritis: a randomized controlled trial. Arthritis Rheum. 2009 Nov 15. 61(11):1545-53. [View Abstract]
  14. Chang WD, Chen S, Lee CL, Lin HY, Lai PT. The Effects of Tai Chi Chuan on Improving Mind-Body Health for Knee Osteoarthritis Patients: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2016. 2016:1813979. [View Abstract]
  15. Magni NE, McNair PJ, Rice DA. The effects of resistance training on muscle strength, joint pain, and hand function in individuals with hand osteoarthritis: a systematic review and meta-analysis. Arthritis Res Ther. 2017 Jun 13. 19 (1):131. [View Abstract]
  16. Osteras N, Kjeken I, Smedslund G, et al. Exercise for Hand Osteoarthritis: A Cochrane Systematic Review. J Rheumatol. 2017 Dec. 44 (12):1850-8. [View Abstract]
  17. Bieler T, Siersma V, Magnusson SP, Kjaer M, Beyer N. Exercise induced effects on muscle function and range of motion in patients with hip osteoarthritis. Physiother Res Int. 2017 Oct 3. [View Abstract]
  18. Kuru Colak T, Kavlak B, Aydogdu O, et al. The effects of therapeutic exercises on pain, muscle strength, functional capacity, balance and hemodynamic parameters in knee osteoarthritis patients: a randomized controlled study of supervised versus home exercises. Rheumatol Int. 2017 Mar. 37 (3):399-407. [View Abstract]
  19. Marks R, Allegrante JP. Chronic osteoarthritis and adherence to exercise: a review of the literature. J Aging Phys Act. 2005 Oct. 13(4):434-60. [View Abstract]
  20. Amaral DS, Duarte ALBP, Barros SS, et al. Assistive devices: an effective strategy in non-pharmacological treatment for hand osteoarthritis-randomized clinical trial. Rheumatol Int. 2018 Mar. 38 (3):343-51. [View Abstract]
  21. Shankland B, Beaton D, Ahmed S, Nedelec B. Effects of client-centered multimodal treatment on impairment, function, and satisfaction of people with thumb carpometacarpal osteoarthritis. J Hand Ther. 2017 Jul - Sep. 30 (3):307-13. [View Abstract]
  22. [Guideline] Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012 Apr. 64 (4):465-74. [View Abstract]
  23. Petersen SG, Beyer N, Hansen M, Holm L, Aagaard P, Mackey AL, et al. Nonsteroidal anti-inflammatory drug or glucosamine reduced pain and improved muscle strength with resistance training in a randomized controlled trial of knee osteoarthritis patients. Arch Phys Med Rehabil. 2011 Aug. 92(8):1185-93. [View Abstract]
  24. Huang Z, Ding C, Li T, Yu SP. Current status and future prospects for disease modification in osteoarthritis. Rheumatology (Oxford). 2018 May 1. 57 (suppl_4):iv108-23. [View Abstract]
  25. Newberry SJ, FitzGerald J, SooHoo NF, et al. Treatment of Osteoarthritis of the Knee: An Update Review. Comparative Effectiveness Reviews, No. 190. 2017 May. [View Abstract]
  26. Pareek A, Chandurkar N, Ambade R, Chandanwale A, Bartakke G. Efficacy and safety of etodolac-paracetamol fixed dose combination in patients with knee osteoarthritis flare-up: a randomized, double-blind comparative evaluation. Clin J Pain. 2010 Sep. 26(7):561-6. [View Abstract]
  27. Godwin M, Dawes M. Intra-articular steroid injections for painful knees. Systematic review with meta-analysis. Can Fam Physician. 2004 Feb. 50:241-8. [View Abstract]
  28. Lambert RG, Hutchings EJ, Grace MG, Jhangri GS, Conner-Spady B, Maksymowych WP. Steroid injection for osteoarthritis of the hip: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2007 Jul. 56(7):2278-87. [View Abstract]
  29. Conaghan PG, Hunter DJ, Cohen SB, et al. Effects of a Single Intra-Articular Injection of a Microsphere Formulation of Triamcinolone Acetonide on Knee Osteoarthritis Pain: A Double-Blinded, Randomized, Placebo-Controlled, Multinational Study. J Bone Joint Surg Am. 2018 Apr 18. 100 (8):666-77. [View Abstract]
  30. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017 May 16. 317 (19):1967-75. [View Abstract]
  31. Bellamy N, Campbell J, Robinson V, et al. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;. CD005321:
  32. Stitik TP, Blacksin MF, Stiskal DM, Kim JH, Foye PM, Schoenherr L, et al. Efficacy and safety of hyaluronan treatment in combination therapy with home exercise for knee osteoarthritis pain. Arch Phys Med Rehabil. 2007 Feb. 88(2):135-41. [View Abstract]
  33. Waddell DD, Kolomytkin OV, Dunn S, Marino AA. Hyaluronan suppresses IL-1beta-induced metalloproteinase activity from synovial tissue. Clin Orthop Relat Res. 2007 Dec. 465:241-8. [View Abstract]
  34. Goldberg VM, Buckwalter JA. Hyaluronans in the treatment of osteoarthritis of the knee: evidence for disease-modifying activity. Osteoarthritis Cartilage. 2005 Mar. 13(3):216-24. [View Abstract]
  35. Bert J, Kenney J, Sgaglione NA, et al. Viscosupplementation for Osteoarthritis of the Knee: A Key Opinion Leader Panel Discussion. J Manag Care Spec Pharm. 2018 Jun. 24 (6-a Suppl):S2-S8. [View Abstract]
  36. Spaková T, Rosocha J, Lacko M, Harvanová D, Gharaibeh A. Treatment of knee joint osteoarthritis with autologous platelet-rich plasma in comparison with hyaluronic acid. Am J Phys Med Rehabil. 2012 May. 91(5):411-7. [View Abstract]
  37. Ahmad HS, Farrag SE, Okasha AE, et al. Clinical outcomes are associated with changes in ultrasonographic structural appearance after platelet-rich plasma treatment for knee osteoarthritis. Int J Rheum Dis. 2018 May. 21 (5):960-6. [View Abstract]
  38. Andia I, Maffulli N. Platelet-rich plasma for managing pain and inflammation in osteoarthritis. Nat Rev Rheumatol. 2013 Dec. 9 (12):721-30. [View Abstract]
  39. van Buul GM, Koevoet WL, Kops N, et al. Platelet-rich plasma releasate inhibits inflammatory processes in osteoarthritic chondrocytes. Am J Sports Med. 2011 Nov. 39 (11):2362-70. [View Abstract]
  40. Fioravanti A, Fabbroni M, Cerase A, Galeazzi M. Treatment of erosive osteoarthritis of the hands by intra-articular infliximab injections: a pilot study. Rheumatol Int. 2009 Jun. 29 (8):961-5. [View Abstract]
  41. Bateman ME, Strong AL, Gimble JM, Bunnell BA. Concise Review: Using Fat to Fight Disease: A Systematic Review of Nonhomologous Adipose-Derived Stromal/Stem Cell Therapies. Stem Cells. 2018 Sep. 36 (9):1311-28. [View Abstract]
  42. Frecklington M, Dalbeth N, McNair P, et al. Footwear interventions for foot pain, function, impairment and disability for people with foot and ankle arthritis: A literature review. Semin Arthritis Rheum. 2018 Jun. 47 (6):814-24. [View Abstract]
  43. Bennell KL, Bowles KA, Payne C, et al. Lateral wedge insoles for medial knee osteoarthritis: 12 month randomised controlled trial. BMJ. 2011 May 18. 342:d2912. [View Abstract]
  44. Nerot A, Nicholls M. Clinical study on the unloading effect of hip bracing on gait in patients with hip osteoarthritis. Prosthet Orthot Int. 2017 Apr. 41 (2):127-33. [View Abstract]
  45. Cudejko T, van der Esch M, van der Leeden M, et al. Effect of Soft Braces on Pain and Physical Function in Patients With Knee Osteoarthritis: Systematic Review With Meta-Analyses. Arch Phys Med Rehabil. 2018 Jan. 99 (1):153-63. [View Abstract]
  46. Healy A, Farmer S, Pandyan A, Chockalingam N. A systematic review of randomised controlled trials assessing effectiveness of prosthetic and orthotic interventions. PLoS One. 2018. 13 (3):e0192094. [View Abstract]
  47. Phang JK, Kwan YH, Goh H, et al. Complementary and alternative medicine for rheumatic diseases: A systematic review of randomized controlled trials. Complement Ther Med. 2018 Apr. 37:143-57. [View Abstract]
  48. Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for hip osteoarthritis. Cochrane Database Syst Rev. 2018 May 5. 5:CD013010. [View Abstract]
  49. Perlman AI, Ali A, Njike VY, et al. Massage therapy for osteoarthritis of the knee: a randomized dose-finding trial. PLoS One. 2012. 7 (2):e30248. [View Abstract]
  50. Cortes Godoy V, Gallego Izquierdo T, Lazaro Navas I, Pecos Martín D. Effectiveness of massage therapy as co-adjuvant treatment to exercise in osteoarthritis of the knee: a randomized control trial. J Back Musculoskelet Rehabil. 2014. 27 (4):521-9. [View Abstract]
  51. Ali A, Rosenberger L, Weiss TR, Milak C, Perlman AI. Massage Therapy and Quality of Life in Osteoarthritis of the Knee: A Qualitative Study. Pain Med. 2017 Jun 1. 18 (6):1168-75. [View Abstract]
  52. Cherian JJ, Kapadia BH, Bhave A, et al. Use of Transcutaneous Electrical Nerve Stimulation Device in Early Osteoarthritis of the Knee. J Knee Surg. 2015 Aug. 28 (4):321-7. [View Abstract]
  53. Elbadawy MA. Effectiveness of Periosteal Stimulation Therapy and Home Exercise Program in the Rehabilitation of Patients With Advanced Knee Osteoarthritis. Clin J Pain. 2017 Mar. 33 (3):254-63. [View Abstract]
  54. Maeda T, Yoshida H, Sasaki T, Oda A. Does transcutaneous electrical nerve stimulation (TENS) simultaneously combined with local heat and cold applications enhance pain relief compared with TENS alone in patients with knee osteoarthritis?. J Phys Ther Sci. 2017 Oct. 29 (10):1860-4. [View Abstract]
  55. Palmer S, Domaille M, Cramp F, et al. Transcutaneous electrical nerve stimulation as an adjunct to education and exercise for knee osteoarthritis: a randomized controlled trial. Arthritis Care Res (Hoboken). 2014 Mar. 66 (3):387-94. [View Abstract]
  56. Ramanathan D, Saleh A, Klika AK, Higuera CA, Barsoum WK. The Use of Transcutaneous Electrical Nerve Stimulation After Total Knee Arthroplasty: A Prospective Randomized Controlled Trial. Surg Technol Int. 2017 Jul 25. 30:425-34. [View Abstract]
  57. Liu H, Abbott J, Bee JA. Pulsed electromagnetic fields influence hyaline cartilage extracellular matrix composition without affecting molecular structure. Osteoarthritis Cartilage. 1996 Mar. 4(1):63-76. [View Abstract]
  58. Zizic TM, Hoffman KC, Holt PA, Hungerford DS, O'Dell JR, Jacobs MA, et al. The treatment of osteoarthritis of the knee with pulsed electrical stimulation. J Rheumatol. 1995 Sep. 22(9):1757-61. [View Abstract]
  59. Sutbeyaz ST, Sezer N, Koseoglu BF. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rheumatol Int. 2006 Feb. 26 (4):320-4. [View Abstract]
  60. McCarthy CJ, Callaghan MJ, Oldham JA. Pulsed electromagnetic energy treatment offers no clinical benefit in reducing the pain of knee osteoarthritis: a systematic review. BMC Musculoskelet Disord. 2006 Jun 15. 7:51. [View Abstract]
  61. Negm A, Lorbergs A, Macintyre NJ. Efficacy of low frequency pulsed subsensory threshold electrical stimulation vs placebo on pain and physical function in people with knee osteoarthritis: systematic review with meta-analysis. Osteoarthritis Cartilage. 2013 Sep. 21 (9):1281-9. [View Abstract]
  62. Birmingham TB, Moyer R, Leitch K, et al. Changes in biomechanical risk factors for knee osteoarthritis and their association with 5-year clinically important improvement after limb realignment surgery. Osteoarthritis Cartilage. 2017 Dec. 25 (12):1999-2006. [View Abstract]
  63. Mandl LA, Martin GM. Overview of surgical therapy of hip and knee arthritis. UpToDate. Updated 2018 Aug 13.
  64. Vissers MM, Bussmann JB, Verhaar JA, Arends LR, Furlan AD, Reijman M. Recovery of physical functioning after total hip arthroplasty: systematic review and meta-analysis of the literature. Phys Ther. 2011 May. 91(5):615-29. [View Abstract]
  65. Elbaz A, Debbi EM, Segal G, Haim A, Halperin N, Agar G, et al. Sex and Body Mass Index Correlate With Western Ontario and McMaster Universities Osteoarthritis Index and Quality of Life Scores in Knee Osteoarthritis. Arch Phys Med Rehabil. 2011 Oct. 92(10):1618-23. [View Abstract]
  66. Messier SP, Legault C, Loeser RF, Van Arsdale SJ, Davis C, Ettinger WH, et al. Does high weight loss in older adults with knee osteoarthritis affect bone-on-bone joint loads and muscle forces during walking?. Osteoarthritis Cartilage. 2011 Mar. 19(3):272-80. [View Abstract]
  67. Dunlop DD, Song J, Semanik PA, Sharma L, Chang RW. Physical activity levels and functional performance in the osteoarthritis initiative: a graded relationship. Arthritis Rheum. 2011 Jan. 63(1):127-36. [View Abstract]
  68. Cakar M, Ayanoglu S, Cabuk H, Seyran M, Dedeoglu SS, Gurbuz H. Association between vitamin D concentrations and knee pain in patients with osteoarthritis. PeerJ. 2018. 6:e4670. [View Abstract]
  69. Tantavisut S, Tanavalee A, Honsawek S, et al. Effect of vitamin E on oxidative stress level in blood, synovial fluid, and synovial tissue in severe knee osteoarthritis: a randomized controlled study. BMC Musculoskelet Disord. 2017 Jun 29. 18 (1):281. [View Abstract]
  70. Weber J, Koch M, Angele P, Zellner J. The role of meniscal repair for prevention of early onset of osteoarthritis. J Exp Orthop. 2018 Apr 2. 5 (1):10. [View Abstract]
  71. Ali SA, Kokorelias KM, MacDermid JC, Kloseck M. Education and Social Support as Key Factors in Osteoarthritis Management Programs: A Scoping Review. Arthritis. 2018. 2018:2496190. [View Abstract]
  72. Arokoski JP. Physical therapy and rehabilitation programs in the management of hip osteoarthritis. Eura Medicophys. 2005 Jun. 41(2):155-61. [View Abstract]
  73. [Guideline] Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000 Sep. 43 (9):1905-15. [View Abstract]
  74. Stitik TP, Levy JA. Viscosupplementation (biosupplementation) for osteoarthritis. Am J Phys Med Rehabil. 2006 Nov. 85(11 Suppl):S32-50. [View Abstract]
  75. Altman RD, Moskowitz R. Intraarticular sodium hyaluronate (Hyalgan) in the treatment of patients with osteoarthritis of the knee: a randomized clinical trial. Hyalgan Study Group. J Rheumatol. 1998 Nov. 25(11):2203-12. [View Abstract]
  76. Ying KN, While A. Pain relief in osteoarthritis and rheumatoid arthritis: TENS. Br J Community Nurs. 2007 Aug. 12(8):364-71. [View Abstract]
  77. Selfe TK, Taylor AG. Acupuncture and osteoarthritis of the knee: a review of randomized, controlled trials. Fam Community Health. 2008 Jul-Sep. 31(3):247-54. [View Abstract]

This radiograph demonstrates osteoarthritis of the right hip, including the finding of sclerosis at the superior aspect of the acetabulum. Frequently, osteoarthritis at the hip is a bilateral finding, but it may occur unilaterally in an individual who has a previous history of hip trauma that was confined to that one side.

This radiograph demonstrates osteoarthritis of bilateral knees. Radiographic findings of osteoarthritis are often graded using the Kellgren-Lawrence Grading System. These knees would be classified as Kellgren-Lawrence grade 3.

Osteoarthritis of the knee, Kellgren-Lawrence grade 3.

Osteoarthritis of the bilateral knees, Kellgren-Lawrence grade 2.

Osteoarthritis of the cervical spine, anteroposterior view.

This radiograph demonstrates osteoarthritis of the right hip, including the finding of sclerosis at the superior aspect of the acetabulum. Frequently, osteoarthritis at the hip is a bilateral finding, but it may occur unilaterally in an individual who has a previous history of hip trauma that was confined to that one side.

This radiograph shows a knee without significant osteoarthritis (for comparison with radiographs demonstrating osteoarthritis).

This radiograph (lateral view) demonstrates a knee without significant osteoarthritis (for comparison with osteoarthritis radiographs).

This radiograph demonstrates osteoarthritis of bilateral knees. Radiographic findings of osteoarthritis are often graded using the Kellgren-Lawrence Grading System. These knees would be classified as Kellgren-Lawrence grade 3.

Osteoarthritis of the knee, Kellgren-Lawrence grade 3.

Osteoarthritis of the knee, Kellgren-Lawrence grade 3.

Osteoarthritis of the bilateral knees, Kellgren-Lawrence grade 2.

Osteoarthritis of the right knee, Kellgren-Lawrence grade 2.

Osteoarthritis of the left knee, Kellgren-Lawrence grade 2.

This radiograph demonstrates osteoarthritis of the cervical spine. Note the bridging osteophytes between the spinous processes, as well as the significant degree of degenerative disk disease.

This radiograph demonstrates osteoarthritis of the cervical spine. Note the bridging osteophytes seen between the spinous processes.

Osteoarthritis of the cervical spine, anteroposterior view.

Osteoarthritis of the elbow is not commonly seen; however, it can occur with a history of previous trauma.

Osteoarthritis of the elbow is not commonly seen; however, it can occur with a history of previous trauma.

Osteoarthritis of the elbow is not commonly seen; however, it can occur with a history of previous trauma.