Osteoarthritisfacts [621994]

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Osteoarthritisfacts [621994]

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Osteoarthritisfacts

facts
Osteoarthritis
SECOND EDITION
DANIEL
PRIETO-ALHAMBRA
Senior Clinical Research Fellow
Nuffield Department of Orthopaedics, Rheumatology
and Musculoskeletal Sciences
University of Oxford, UK
NIGEL ARDEN
Professor in Rheumatic Diseases
Director of Musculoskeletal Epidemiology and Biobank
University of Oxford and Southampton, UK
DAVID J. HUNTER
Florance and Cope Chair of Rheumatology
and Professor of Medicine
Institute of Bone and Joint Research, Kolling Institute
University of Sydney and Royal North Shore Hospital,
Australia
1

1
Great Clarendon Street, Oxford, OX2 6DP, United KingdomOxford University Press is a department of the University of Oxford.It furthers the University’s objective of excellence in research, scholarship,and education by publishing worldwide. Oxford is a registered trade mark ofOxford University Press in the UK and in certain other countries© Oxford University Press 2014The moral rights of the authors have been assertedFirst Edition published in 2008Impression: 1All rights reserved. No part of this publication may be reproduced, stored ina retrieval system, or transmitted, in any form or by any means, without theprior permission in writing of Oxford University Press, or as expressly permittedby law, by licence or under terms agreed with the appropriate reprographicsrights organization. Enquiries concerning reproduction outside the scope of theabove should be sent to the Rights Department, Oxford University Press, at the address aboveY ou must not circulate this work in any other form and you must impose this same condition on any acquirerPublished in the United States of America by Oxford University Press 198 Madison Avenue, New Y ork, NY 10016, United States of AmericaBritish Library Cataloguing in Publication DataData availableLibrary of Congress Control Number: 2014933295ISBN 978–0–19–968391–8Printed and bound by Ashford Colour Press Ltd, Gosport, HampshireOxford University Press makes no representation, express or implied, that thedrug dosages in this book are correct. Readers must therefore always checkthe product information and clinical procedures with the most up-to-datepublished product information and data sheets provided by the manufacturersand the most recent codes of conduct and safety regulations. The authors andthe publishers do not accept responsibility or legal liability for any errors in thetext or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feedingLinks to third party websites are provided by Oxford in good faith andfor information only. Oxford disclaims any responsibility for the materialscontained in any third party website referenced in this work.

vAcknowledgements
T o all the patients that I have had the opportunity to care for, thank you for the
privilege.
T o David’s adoring and beautiful wife Jo and four fantastic children (Jordan, Sam,
Charlie, and Hannah), thank you for giving me a full and complete life, and for
understanding when my obsession with my profession compromises our time together.
T o my friends, colleagues, and family who read and edited this book, thank you for
your help and encouragement.
DH
T o Maria, to Pau, and to little Bella
DPA

viiContents
Abbreviations ix
Introduction to osteoarthritis xi
Part one
Background to osteoarthritis
1 What is osteoarthritis? 3
2 Why we get osteoarthritis and how to prevent it 11
3 Symptoms and signs 21
4 How is osteoarthritis diagnosed? 29
5 The outlook or prognosis 39
Part two
Management of osteoarthritis
6 The management of osteoarthritis—an overview 51
7 The role of exercise 65
8 The role of diet and weight loss 79
9 Complementary or alternative therapy 91
10 Medicines used in osteoarthritis 101
11 Device use and other therapies for osteoarthritis management 119
12 Surgical therapy 127
13 Depression and coping 143

Osteoarthritis · facts
viii 14 Which health professionals are involved in OA management?:
making the most of your healthcare team 157
Appendix 1 A typical case history 169
Appendix 2 Useful addresses 173
Glossary 177
Index 183

ixAbbreviations
ACL anterior cruciate ligament
AC acromioclavicular
ACR American College of Rheumatology
ARC Arthritis and Rheumatism Council
ACI autologous chondrocyte implantation
ACT autologous chondrocyte therapy
BMI body mass index
CBT cognitive behaviour therapy
CT computed tomography
DIP distal interphalangeal
ESR erythrocyte sedimentation rate
EFA essential fatty acid
EULAR European League Against Rheumatism
FIFA Fédération Internationale de Football Association
FDA Food and Drug Administration
GP general practitioner
IOC International Olympic Committee
IU international units
kcal kilocalorie
kJ kilojoule
MRI magnetic resonance imaging
MCP metacarpophalangeal
MAOI monoamine oxidase inhibitors
NSAID non-steroidal anti-inflammatory drug
OT occupational therapist
OA osteoarthritis
OMM osteopathic manual medicine or osteopathic manipulative medicine
PM&R physical medicine and rehabilitation
PCP primary care physician
PMR progressive muscle relaxation

Osteoarthritis · facts
xPIP proximal interphalangeal
SSRI selective serotonin reuptake inhibitor
SR strontium ranelate
THR total hip replacement
TKR total knee replacement
TENS transcutaneous electrical nerve stimulation
TCA tricyclic

xiIntroduction
to osteoarthritis
Osteoarthritis is an increasingly common problem in our community. Many
individuals with arthritis are affected by pain, stiffness, or some loss of func –
tion, and are dealing with a disease that is long-lasting. We (the authors)
strongly believe that the crux of any successful treatment is empowering
patients with the knowledge and skills they need to help themselves. This kind
of self-management approach to treating osteoarthritis is what we want to
encourage the readers of this book to take up. It means actively taking charge
of your own health by knowing as much as you can about osteoarthritis, and
finding out how it can be best managed.
First, if you want to take charge of your own treatment, you need to under –
stand the disease processes that can cause osteoarthritic symptoms. Part 1
details what osteoarthritis is and gives information about what causes it, who
it affects, what symptoms are associated with osteoarthritis, how it is diag –
nosed, and the long-term outlook.
Part 2 then explains the many potential aspects of management that can be
used for osteoarthritis. This includes explaining what self-management strate –
gies are, the range of health professionals that may assist you in managing
your osteoarthritis, and a description of exercise, diet, all the different medi –
cines that are used, their efficacy and their side effects, surgical treatments,
and what alternative therapies there are.
Informing yourself about what conventional medical treatments are avail –
able to treat osteoarthritis is empowering. It is also important to know which
healthcare practitioners (including doctors, physiotherapists, dietitians, etc.)
are involved in osteoarthritis treatment so you that know who can help when
particular problems arise.

Osteoarthritis · facts
xiiThere is a wealth of information on complementary treatments for arthritis.
Some of these treatments are helpful, others less so. Most importantly, you
should be aware of those that are likely to be of benefit and those that may
do harm.
Unfortunately, many people with osteoarthritis are encouraged to rest, or they
are provided with a tablet as the only means of helping their pain. However,
there is a great deal of scientific research that commends the importance of
exercise and a well-balanced diet in managing osteoarthritis. Personal issues
such as pain management, fatigue, depression, and relationships can be serious
for someone with arthritis, and managing these well can make a big difference.
If you want to find out more, there’s also information in Appendix 2 on what
other resources are out there that may help you, such as support groups and
websites.
Finally, it is important to note that this book is not intended to be a substi –
tute for appropriate medical care. Rather, it is an opportunity for people with
osteoarthritis to educate and empower themselves with tools that will help
reduce their suffering.

1Part 1
Background
to osteoarthritis

3There are over 100 different types of arthritis that can affect joints in the body
but ‘osteoarthritis’ is the most common type of joint disorder in the world today,
affecting the majority of those of us over the age of 65. The recent burden of
disease estimates suggest that upwards of 250 million people have osteoarthri –
tis and due to the increasing size of the elderly population and obesity in the
Western world as well as in developing countries this figure is likely to increase
in number.
Although the disease is common, the degree to how it can affect us in our lives
varies enormously between individuals. For some, osteoarthritis can have a
detrimental impact on their lives while for others the condition may be little
more than an inconvenience.
The history of osteoarthritis
Osteoarthritis is not a new disease; in fact it has been around for many years.
Scientists discovered when examining the skeletons of humans and mammals 1
What is osteoarthritis?
% Key points
◆ Osteoarthritis (OA) is the most common type of joint disorder.
◆ It is a chronic condition of the synovial joint causing pain and stiffness
and sometimes inflammation and swelling.
◆ It involves all of the structures of the joint.
◆ It has a large individual impact due to effects on the quality of life as
well as large socioeconomic consequences due to it being so common
and costly.
◆ It is important to understand as much as possible about the condition
as this will help in future management of the OA.

Osteoarthritis · facts
4from as long ago as the ice age that joints had osteoarthritis. From the time of
Hippocrates until approximately 250 years ago, all forms of chronic arthritis
were considered to be manifestations of gout. The first break with that under –
standing came in 1782, when William Heberden described the nodes that now
bear his name, highlighting that ‘they have no connexion with gout’. Debate
over the nature of the disease continued even after the coining of the term
‘osteoarthritis’ by A.E. Garrod in 1890.
What does osteoarthritis mean?
Like many other medical conditions, osteoarthritis has been acknowledged
as a disease for hundreds of years and its name is derived from the Latin lan –
guage. When the name is translated, ‘osteo’ means bone, ‘arthro’ means joints,
and ‘itis’ means inflammation. Therefore ‘osteoarthritis’ means inflammation
of the bones in the joint. In reality the bone is affected but so is the remainder
of the joint. Despite people using the term ‘osteoarthrosis’ to suggest that this
is not inflammatory, this is incorrect and the ‘itis’ is accurate. It continues to
be called osteoarthritis or OA when abbreviated.
What is osteoarthritis?
For many years musculoskeletal scientists and clinicians have deliberated over
the correct definition of osteoarthritis. They concluded that it is a chronic
condition of the synovial joint that develops over time and is the result of
damaging processes overwhelming the joint’s ability to repair itself. Modern
insights no longer see OA as a passive, degenerative (yes that’s right—the use
of this term is archaic) disorder but rather as an active disease process with
an imbalance between the repair and destruction of joint tissues that is driven
primarily by mechanical factors.
It can affect all of the joint tissues (including bone, ligaments, muscle, and
synovium), not just cartilage. Many define OA as a condition that primar –
ily affects hyaline articular cartilage, including William Hunter who in 1743
stated soberly ‘From Hippocrates to the present age it is universally allowed
that ulcerated cartilage is a troublesome thing and that once destroyed, is not
repaired’. The common misconception that this is a disease of cartilage under –
mines the importance of these other tissues. Cartilage does not contain nerve
fibres so cannot be directly responsible for pain. Besides, recent research sug –
gests that the bone underlying the articular cartilage also plays an essential
role in the development and progression of OA. For this reason osteoarthritis
is now recognized as a disease of the whole joint.

chapter 1 · What is osteoarthritis?
5Osteoarthritis—‘a chronic disease’
A chronic condition differs from that of an acute illness, such as appendi –
citis or the flu, in that an acute illness has a start and an end to the illness,
often with a treatment in the middle. A chronic condition often has a more
gradual onset as opposed to an immediate response to trauma; it is often
ongoing and may never end. Diabetes, heart disease, and hypertension are
other chronic conditions like osteoarthritis that gradually develop over time
and continue to persist. Like other chronic diseases, there is no sole treat –
ment or cure; instead there are several strategies to use that can help manage
the condition.
When the term ‘disease’ is used in this context it does not mean osteoarthritis
is contagious or the result of injury, but that it is a recognized medical disor –
der that is accompanied by symptoms and clinical signs and follows a natural
process.
The joints affected by osteoarthritis
The joints that are most prone to osteoarthritis include the hands and wrists
as well as the weight-bearing joints of the body: the knee, hip, and back. Other
joints such as the ankle, shoulder, and elbow are less likely to develop osteoar –
thritis unless there has been previous trauma to that joint.
What are the signs and symptoms of osteoarthritis?
OA tends to come on slowly, over months or even years. The symptoms for
those who have osteoarthritis consist of pain and stiffness (the latter is often
relieved in a few minutes by movement) in the affected joints although they
vary between individuals. Early in the disease course the pain is experienced
with activity, although in later stages of disease it can occur at rest. In some
cases the pain can lead to reduced movement, which in turn limits the func –
tion of the joint. In severe cases inflammation can develop, causing the joint
to become swollen and warm. The signs that clinicians identify as part of the
osteoarthritis condition include swelling, reduced range of motion, joint ten –
derness and bony enlargement around the joint, and crepitus (creaking of the
joint when moved).
The joint with osteoarthritis
The synovial joint is made up of two bone ends, a layer of cartilage lining the
end of each bone, a capsule lined by synovium which produces synovial fluid,

Osteoarthritis · facts
6
Bone
Synovium
Capsul e
Cart ilage
Ligament
BoneTendonMuscle
Meniscus(knee only)
Figure 1.1 The normal synovial joint without osteoarthritis
ligaments, tendons, and muscles (Figure 1.1). The role of cartilage, which
when healthy is usually smooth, firm, white, and rubbery in nature, is to help
the bone ends move smoothly and painlessly against each other when the joint
is moved.
Synovial fluid is a viscous fluid of a similar consistency to car engine oil and
also helps the joint ends move easily by acting as a lubricant. As a result we
move joints naturally, often without noticing the action.
The tendons attach the muscles to bone and are involved in moving and sta –
bilizing the joints. The ligaments attach the two bones together and help to
stabilize the joint at rest and during movement.
The bone tissue and cartilage are always undergoing regeneration and as long
as this continues the joints work smoothly together. In osteoarthritis the dam –
aging forces overcome the joint’s reparative ability.
The joint with mild osteoarthritis
Figure 1.2 shows a joint with mild osteoarthritic changes. As you will see, the
cartilage over time has become thinner, scantier, and less smooth in appear –
ance such that the two bones do not move as smoothly during joint move –
ment. The space between the bone ends has also become narrower due to the
thinning of the cartilage, and as a result more pressure is put on the tendons
and ligaments to maintain joint stability. In response to the depleted cartilage
and imbalance the bone starts to grow little bony spurs called ‘osteophytes’.

chapter 1 · What is osteoarthritis?
7
Osteophytes
(spurs )Mildlythickene d,
inf
lame d
synovium
/T_hickened ,
stretche d
capsul e
Roughene d,
thinnin g
cartilage
Figure 1.2 A synovial joint with mild osteoarthritis
The joint with severe osteoarthritis
Y ou can see in Figure 1.3 that there is now much greater cartilage loss, includ –
ing areas where the cartilage has disappeared, exposing the underlying bones.
The osteophytes are now bigger and the bone ends start to thicken in response
to the increased stresses that they encounter due to the loss of the shock-
absorbing effect of the overlying cartilage. As the cartilage breaks down, debris
can be found in the synovial fluid, which is struggling to produce enough
lubricant for the bone ends and remaining cartilage.
/T_hickened ,
crunched-up
bone with no
covering
cartilage
OsteophyteInf lame d
synovium
Tight
thickene d
capsul e
Little r emaining
cartilageBoneangulation(deformit y)
Figure 1.3 A synovial joint with severe osteoarthritis

Osteoarthritis · facts
8This advanced stage of osteoarthritis results in pain, stiffness, and inflamma –
tion as the joint struggles to maintain its smooth function.
Other names for osteoarthritis
‘Wear and tear’, ‘degenerative changes’, ‘osteoarthrosis’, ‘degenerative joint
disease’, ‘degenerative arthritis’, and ‘decaying cartilage’ are all common
expressions used by physicians when describing osteoarthritis to a patient;
however, they all mean osteoarthritis. Some of these can sound quite cata –
strophic and most are inaccurate but sadly many people continue to use them.
What about rheumatoid arthritis
and osteoporosis?
Osteoarthritis is a joint disease. Unlike many other forms of arthritis that are
systemic illnesses, such as rheumatoid arthritis, scleroderma, and lupus, osteo –
arthritis does not affect other organs of the body. Medical conditions and their
names can be very confusing and some people get muddled with ‘rheumatoid
arthritis’, ‘osteoporosis’, and ‘osteoarthritis’. It should be noted that although
they are all rheumatological conditions they are very different diseases.
Rheumatoid arthritis (RA) is a condition where the synovium becomes inflamed
and causes severe damage to the cartilage and bone. It is less common than
osteoarthritis, presents with different signs and symptoms, and its treatment is
quite different to osteoarthritis.
Osteoporosis is a disease of bones leading to an increased risk of fracture. It
does not affect the joints and rarely causes joint pain. The treatment by physi –
cians is quite different to that of osteoarthritis.
The impact of osteoarthritis in the general
population
Osteoarthritis is common, especially in the elderly, and as such it causes
strains to both the medical services and the financial welfare of the country.
For example, in the USA it accounts for 315 million visits to the doctor per
year, approximately 744,000 hospital admissions per year, and amounts to
68 million days off work. In recent years osteoarthritis has been seen as the
second biggest cause of work disability in those aged 50 and over, ischaemic
heart disease being in first position, and therefore is of major concern, as it has
significant implications on the welfare state.

chapter 1 · What is osteoarthritis?
9The impact of osteoarthritis on each individual
Of course not everybody with osteoarthritis will have to visit a doctor or be
admitted to hospital, and not everybody will stop work due to the condition.
As you will discover in this book, osteoarthritis affects people to different lev –
els. For some people osteoarthritis can have a major impact on their lifestyle,
but for many it may cause just a minor disruption and some people have virtu –
ally no symptoms at all, often unaware that they have signs of osteoarthritis.
For some people the disease only affects the one joint while for others the
disease can be widespread and continue to progress, so affecting movement,
causing pain and distress, and impacting on private and working lifestyles,
sometimes leading to surgical treatments. In conclusion, we are all individuals
and our experience of osteoarthritis will vary.
In summary
Osteoarthritis is a chronic or long-term disease of the synovial joints associ –
ated with pain and stiffness. The impact and experience of osteoarthritis vary
between individuals; however, the one thing clinicians know is that the more
information people have about their osteoarthritis the more in control they
feel and the easier it is to manage. There are many sources of good informa –
tion but a good place to start is your local doctor and the arthritis organization
in your country (see Appendix 2).

11We now know from the previous chapter (Chapter 1) that osteoarthritis is a chron –
ic condition that is characterized by well-defined changes on X-ray and associated
with pain and joint stiffness: but why do we develop it? Clinicians and research
scientists have, over the past couple of decades, studied people who have been
diagnosed with osteoarthritis. The research has focused on the following areas:
◆ Lifestyles which include body weight, the nature of current or previous
type of work, type of diet, and level of activity throughout life.
◆ Past medical histories including injuries to joints, previous surgery, and
other medical conditions.
◆ Family history, examining osteoarthritis within families to establish if
there are any connections to it having a genetic connection.2
Why we get
osteoarthritis
and how to prevent it
% Key points
◆ Research plays a key role in helping us understand why we get OA.
◆ There are some general factors affecting our joints and also some spe –
cific factors that increase our risk of developing OA.
◆ Some factors we have no control over (age, genetics) but other factors
such as fitness and obesity we are able to modulate.
◆ The more we understand the reasons as to why we develop OA, the
easier it is to accept the condition and manage it.

Osteoarthritis · facts
12By studying these three main areas researchers have gained insight into the
factors that can influence the development of osteoarthritis in individuals.
These influential factors are called ‘risk factors’ in the medical profession and
they can be split into two main groups:
1. ‘Systemic’ or general risk factors that can affect ‘any’ joint developing OA.
These include age, genetics, bone density, nutrition, and ethnic group.
2. ‘Local’ risk factors that affect specific joints of the body such as obesity,
previous job, trauma/injury, and congenital medical conditions.
Although many risk factors have been identified for osteoarthritis, like many
other chronic conditions there is not always one single factor responsible for
the disease: for example, you could be overweight and also have a family his –
tory of osteoarthritis. We term this multifactorial. Coronary heart disease is a
good example of this as it too has many risk factors associated with its onset:
smoking, diabetes, stress, obesity, high cholesterol levels, lack of fitness, genetic
make-up, and so on. Patients presenting with coronary heart disease are often
Injur y
AlignmentLimb leng th in equality
Struct ural abnormalit y (menis cal tear, ACL tear )
Bridging Mu scle W eakness Physical activi ty
Susceptible join t
Susceptible individualOsteoart hritisAge
Streng thObesity
Physical
Activi ty
Obesity
Age
Race/Ethnicit y Dietary Factor s
Bone meta bolismGenetic Pr edisposition
GenderMedical/
Psychoso cial
Comorb idityOA-related
DisabilityPain intensit y
Pain duration
Multisite Pain
Baseline di sabilityMuscle weakness
Bone shap e
Occupation
Figure 2.1 Risk factors for osteoarthritis and related disability
Adapted from PM&R , Volume 4, Issue 5, Pradeep Suri, David C. Morgenroth, and David J. Hunter,
Epidemiology of Osteoarthritis and Associated Comorbidities, pp. S10–S19, Copyright © 2012
American Academy of Physical Medicine and Rehabilitation, with permission from Elsevier,
<http://www.sciencedirect.com/science/journal/19341482>

chapter 2 · Why we get osteoarthritis and how to prevent it
13found to have more than one of these risk factors. In today’s society the two
biggest risk factors for knee OA are obesity and joint injury. The risk for knee
OA in our society attributed to these two risk factors accounts for approxi –
mately 80 per cent of the reasons for OA development (see Figure 2.1).
The aim of this chapter is to examine the ‘risk factors’ that can influence
the disease onset and progression of osteoarthritis and in so doing hopefully
answer some of your questions and address some of the myths surrounding
the cause of osteoarthritis.
Systemic risk factors—general factors affecting
any joint
These risk factors tend to define the ability of the joints to stay healthy and
repair themselves in response to injury or repetitive trauma such as occupa –
tion or sports. A person with no systemic risk factors can work in high-risk
occupations or participate in high-risk sports, such as professional football,
without developing OA, whereas a person with several risk factors may devel –
op OA in low-risk occupations or without participating in any high-risk sports.
Age
Probably the most obvious finding and well-known observation of osteoar –
thritis is that it is generally uncommon in young people and becomes very
common as we all get older. It is thought that by the time we reach the age
of 75 years there is a 90 per cent chance of having osteoarthritis on X-ray
somewhere in the body. However, this does not mean that all of us will have
symptoms.
There are two main reasons why age is such a strong risk factor:
1. Inability of the body to repair joint tissues. During our lives the joints are
working constantly, which is healthy and quite normal, but it does mean
that they have been under a large cumulative ‘joint strain’ over the years.
The cartilage, meniscus, and ligaments diminish in size (osteoarthritis)
and become unable to repair themselves. It is thought that this inability
of the body to repair joint tissues is due to the reduction of growth hor –
mones. Growth hormones are necessary for joint tissue turnover but as we
all age they are reduced as part of the ageing process and the body loses its
ability to repair the cartilage.
2. Changes to our activity and fitness levels. It has been recognized that as we
get older our general fitness decreases, which in turn affects the muscle

Osteoarthritis · facts
14strength. Muscles are needed to support the joints both above and below
a joint; however, when the muscle strength is diminished or reduced then
greater pressure is placed on the joint itself, in particular the cartilage.
Although the prevalence of osteoarthritis increases sharply with age there are
still some people who do not develop osteoarthritis. Scientists believe this may
occur because there are protective mechanisms in place and/or that there are
no other risk factors to influence its onset.
Genetics
The latest evidence to date indicates that half of the risk of developing osteo –
arthritis of the hand and hip (approximately 25 per cent for the knee) can be
attributed to genetic factors. This was first realized for hand OA when doctors
noticed that most patients with Heberden’s nodes had a family member with
the same condition. It is very unlikely that there is a single gene that deter –
mines the genetic risk, but rather a large number of genes. The genes that
have been examined are those responsible for the make-up of joint tissues,
however it is likely that genes determining joint shape, muscle strength, and
body weight will also have important roles to play. However, as previously
mentioned, there are other important risk factors for developing osteoarthritis
and these may modify our genetic risk of developing OA.
Gender
Up until the age of 55 years osteoarthritis affects men and women equally;
however, after the age of 55 women are twice as likely to develop osteoarthri –
tis, particularly at the hand and knee. As most women are postmenopausal
after the age of 55, it is suggested that the drop of oestrogen levels is the factor
responsible for its higher prevalence in women above this age. Research has
shown hormone replacement therapy can slow or delay the onset of osteoar –
thritis but unfortunately it does not prevent the progression of the condition.
As hormone replacement therapy is associated with other medical health risks
if taken for prolonged periods (myocardial infarction and thrombosis and
increased risk of breast cancer), it is not routinely seen as a treatment choice
for osteoarthritis.
Bone density
Research has shown that there is a link between bone density and osteoarthritis.
Those people who have a high bone density are more at risk of osteoarthri –
tis while those with a low bone density are less at risk. Therefore if you have
osteoporosis (low bone density and brittle bones) you are less likely to develop

chapter 2 · Why we get osteoarthritis and how to prevent it
15osteoarthritis. It is thought this could be because the bones are lighter and
more compliant in osteoporosis and therefore put less strain on the cartilage
leading to less wear and tear. This is not to say that osteoporosis is a good dis –
ease to develop as it has serious health risks associated with it. Besides, despite
the protective effect of OA on the risk of osteoporosis, patients with OA are
not protected against fractures: recent data has shown that in fact patients with
symptomatic OA are at a higher risk of osteoporotic fractures, probably due to
an increased risk of falls.
Ethnic groups
Generally speaking, osteoarthritis is prevalent in all ethnic groups around the
world. However, research has shown the rates of osteoarthritis are generally
lower in places where obesity is lower such as China and Asia. Here hip osteo –
arthritis and hand osteoarthritis are found to be one-tenth and one-half of
the numbers found in white Americans respectively. As the incidence is low
in these parts of the world it is thought that there may also be some genet –
ic or other systemic factor that protects them from the development of this
condition.
Studies comparing the rates of osteoarthritis between black and white Americans
in the hip and knee joint found that although the rates were similar, the knee
involvement was more common in black Americans, possibly due to a higher
body mass index.
Nutrition
It has generally been thought that vitamins have played a role in the health of
our joints for many decades and now there is evidence to suggest that they do
have a beneficial role to play, especially in the knee joint. It is suggested that a
diet lacking in either vitamin C, D, or E can affect the health of the joint and
cause osteoarthritis. When the joint tissues are broken down in osteoarthritis,
free oxygen radicals are released. These cause oxidative damage to the remain –
ing cartilage and also the other joint tissues thus leading to the progression of
osteoarthritis. Vitamins C and E are antioxidants (the antidotes) and therefore
have a beneficial role in collagen synthesis and joint health. In fact one study
found those with a diet rich in vitamin C had less knee pain and slower pro –
gression of osteoarthritis.
Vitamin D has an important role in bone metabolism and may improve the
metabolism of the periarticular bone (bone ends) in response to excess load –
ing and joint damage. It may also have direct beneficial effects on cartilage
and improve muscle function and hence stabilize the joint more effectively.

Osteoarthritis · facts
16Studies of people who have high serum levels of vitamin D or high dietary
intake of vitamin D have demonstrated a protective effect in subjects with
knee osteoarthritis.
Very recent studies have suggested that one of the compounds of broccoli
(sulforaphane) can protect cartilage destruction and therefore decrease the
risk of osteoarthritis onset and progression. These data are based in animal
models, and need replication in further studies.
Local mechanical risk factors—factors
that influence the onset in specific joints
Injury
It has now been shown that previous injuries to joints can be a risk factor for
developing osteoarthritis in later years. Acute injuries such as meniscal (car –
tilage) and anterior cruciate ligament (ACL, in the knee) tears and disloca –
tions increase the risk of osteoarthritis in later years in the joint in question.
In general a severe injury of any joint may be followed by osteoarthritis in
later years but you are more susceptible if you already have osteoarthritis of
another joint.
Athletes such as footballers and rugby players are prone to such injuries and
often go on to develop osteoarthritis in later years in those joints where the
injury took place. Unfortunately although surgery can correct injuries at the
time they don’t reduce the risks of developing osteoarthritis in the operated
joint. It is reassuring to know that today in school and at fitness clubs great
emphasis is made on stretching and warming up and cooling down so as to
prevent such injuries.
It is estimated that 25 per cent of knee OA could be prevented by prevent –
ing knee injuries among men (women, 14 per cent). Numerous trials of
neuromuscular conditioning programmes (such as FIFA11 <http://f-marc.
com/11plus/home/>) have demonstrated efficacy in reducing the risk of
ACL injury by as much as 60 per cent. These programmes are simple and
have impact—they typically consist of a warm-up, stretching, strengthening,
plyometrics, and sport-specific agility training—and have generated wide –
spread support from eminent international organizations including the IOC
(International Olympic Committee) and FIFA (Fédération Internationale de
Football Association). Despite the impact of joint injury and the known effi –
cacy of these prevention trials, programme dissemination and implementation
has been limited.

chapter 2 · Why we get osteoarthritis and how to prevent it
17Physical activity and occupation
Recent years have witnessed an enormous increase in the popularity of rec –
reational exercise. In concert with this increase individuals with normal joints
frequently ask whether their exercise programmes increase the risk of develop –
ing osteoarthritis. Generally speaking, moderate exercise is extremely good
for your physical and mental health and does not cause osteoarthritis in later
years. As parents we are often telling our children ‘everything in moderation is
good for you’. There is no evidence that recreational running or sports leads to
an increased risk of OA. However, there are groups of people such as athletes
who train at very high and intense levels, causing extra stress to joints and
exposing themselves to injury, and in so doing increase their risk of osteoar –
thritis in later years. This is mainly true of professional weightlifters, football –
ers, and rugby players.
There are also groups of people in whom evidence shows that repeated joint
loading with some activities can increase the risk of osteoarthritis in later
years. For instance, osteoarthritis of the knee is more common in the Chinese
female population who squat excessively as part of their culture (this despite a
low body weight), osteoarthritis is more common in the hands of cotton mill
workers who put extra stress on their finger joints, and osteoarthritis of the hip
joint is common among farmers (due to a combination of lifting heavy loads
and walking on uneven ground).
Muscle strength and weakness
Generally speaking, good muscle strength is vital for a healthy joint and some
joints have even been shown to have a lower rate of osteoarthritis when sup –
ported well. For example, having strong quadriceps has been shown to reduce
the risk of knee osteoarthritis. However, there are some areas of the body that
can increase the risk of osteoarthritis if the muscle strength is good. Bus driv –
ers, for example, are prone to osteoarthritis as they have a very tight handgrip.
Joint deformity/shape
There are some congenital abnormalities that can increase the risk of osteoar –
thritis in later years. These are usually conditions of the musculoskeletal system
where excess stress is placed on joints due to abnormalities of the joint tissues
or bones, which results in dysfunctional joints. Examples of this are acetabular
dysplasia and slipped capital femoral epiphysis of the hip or bow legs.
Like the knee, recent evidence highlights the importance of local mechani –
cal factors in leading to hip osteoarthritis and 90 per cent or more of hip

Osteoarthritis · facts
18osteoarthritis cases can be attributed to anatomical abnormalities. These ana –
tomical/shape abnormalities are termed femoroacetabular impingement and
this insight into the cause of hip OA is one of the most important and pro –
vocative new tenets in OA.
Obesity
Being overweight is a major concern for health professionals managing all
chronic diseases, heart disease, some cancers, and diabetes to name but a few.
Not surprisingly, being overweight causes extra stress on the ‘weight-bearing’
joints such as the hip and knee and results in an accelerated rate of osteoar –
thritis. It is suggested that for every extra kilogram of body weight your knees
carry an alarming 4 kilograms of extra stress! The effects of being overweight
have a direct effect on the stress of the joint but are also linked to metabolic
changes that can affect the risk of developing hand osteoarthritis. Studies have
shown obesity to be the biggest risk factor for developing osteoarthritis of the
knee and weight loss can reduce the risk of subsequent knee osteoarthritis.
Obesity is the single most important risk factor for development of severe
knee osteoarthritis and more so than other potentially damaging factors,
including injury and family history. Because obesity is both a risk factor for
osteoarthritis and has been increasing in prevalence over the past four dec –
ades, it is likely that more individuals will be affected by knee osteoarthritis
in the future. Societal trends in obesity are concerning, with some projecting
that 86.3 per cent of adults will be overweight or obese and 51.1 per cent
obese by 2030. Prevention of obesity is likely to be challenging and involves
complex strategies including tax on processed foods, supporting healthy food
alternatives, promoting physical activity, restricting unhealthy food advertis –
ing, and appropriate labelling of food. While these strategies may be socially
challenging, weight reduction at the population level as a public health meas –
ure would be very effective in reducing knee and hip osteoarthritis. Focusing
weight reduction efforts on only women age 50 and over could itself prevent
anywhere from 25.1 to 48.3 per cent of knee osteoarthritis in women. Despite
trial evidence of efficacy in weight loss dissemination of this to the wider at-
risk community is limited.
Conclusion
There are many risk factors associated with osteoarthritis and the more risk
factors that you have, the higher the chance you will develop osteoarthritis.
Similarly it should be noted that just because you have one risk factor, it does
not lead you to automatically develop osteoarthritis.

chapter 2 · Why we get osteoarthritis and how to prevent it
19There are some risk factors that we are at present unable to alter, for instance,
ageing and our genetic make-up. However, there are some risk factors that we
are able to influence, for instance, we can alter our lifestyles to encourage a
healthy weight, reduce our risk of joint injury, and maintain an optimal level of
exercise in order to reduce our chances of developing osteoarthritis.
Research is always continuing into this field of osteoarthritis, and it is hoped
that with a better understanding of the different risk factors responsible for
the onset of the disease, in years to come clinicians will be able to develop
some breakthroughs and practise preventative medicine. As individuals it is
hoped that we will be able to play an active role in minimizing the onset of
osteoarthritis.

21Osteoarthritis is a joint disease. Unlike many other forms of arthritis that are
systemic illnesses, such as rheumatoid arthritis, scleroderma, and lupus, oste –
oarthritis does not affect other organs of the body. However, recent data have
suggested an increased risk of cardiovascular disease in people with osteoar –
thritis. Therefore, an accurate assessment of the person as a whole is required
in patients with osteoarthritis.
Symptoms of osteoarthritis vary greatly from person to person. Some peo –
ple can be debilitated by their symptoms whereas others may have remarka –
bly few symptoms in spite of the dramatic degeneration of their joints shown
on X-rays. Symptoms can also be intermittent. It is not unusual for patients
with osteoarthritis of the hands and knees to have years of pain-free intervals
between symptomatic episodes.
The severity of symptoms in osteoarthritis is greatly influenced by a person’s
attitudes, anxiety, depression, or daily activities.
The symptoms and signs of osteoarthritis will also vary depending on the joint
affected. The main symptoms associated with OA are stiff and painful joints.
These do usually impact on your day-to-day function. The main signs relate to
an altered range of motion, crepitus, and tenderness of the joint. This chapter
explains each of these symptoms and signs in more detail.3
Symptoms and signs
% Key points
◆ The main symptoms associated with osteoarthritis are stiff and painful
joints.
◆ The main signs are an altered range of motion, crepitus, and joint
tenderness.
◆ Please seek help from a health professional to make the correct
diagnosis.

Osteoarthritis · facts
22Please remember that the presence of one or even all of these symptoms and
signs does not mean that you have osteoarthritis—many of them can be pro –
duced by other disorders. Please seek help from a health professional to make
the correct diagnosis and do not use this chapter for making your own diagnosis.
Pain
The characteristic pain of osteoarthritis begins gradually, progressing slowly
over many years. Once established, pain may behave like a roller coaster, with
bad spells followed by periods of relative relief. However, there are some patients
who report feeling acute pain and joint swelling as the first signs and symptoms
related to osteoarthritis.
Pain usually comes from deep within the joint. It is generally described as an
aching, sharp, or burning pain. It is also often described as mechanical; that is,
it is worse with activity such as when there is weight or resistance put on the
joint/s affected (for example, walking or climbing stairs and therefore putting
pressure on the knee joint). The pain is usually relieved after resting for a few
minutes.
Sometimes the activity-related pain will persist after long periods of activity
(playing sports, hiking, shovelling snow, working in the garden, or other repeated
activities of daily living) and towards the end of the day. Some people with OA
say that cold and humid weather may increase their pain.
As the disease advances and the structure of the joint is badly damaged, the pain
may occur even when the joint is at rest, and it can keep a sufferer awake at night.
The pain of osteoarthritis usually occurs in the area of the affected joint; how –
ever, in some cases, the pain may be referred to other areas. For example, the
pain of osteoarthritis of the hip may actually be felt in the knee. Although it
has long been thought that this pain originated in the joint itself, recently pub –
lished studies have suggested that in some cases the pain might also originate
in, or ‘amplify’ at, the central nervous system or peripheral nerves.
Stiffness
The joint stiffness associated with osteoarthritis usually follows periods of
inactivity. Usually it is at its worst in the morning on first rising from bed—
lasting less than 30 minutes—and can also be troublesome after resting during
the day. Moving the joint or doing some exercise for a few minutes can help
shake off the stiffness associated with osteoarthritis. Usually the stiffness lasts
for 2–3 minutes and is described as ‘gelling’.

chapter 3 · Symptoms and signs
23Long-lasting (for over 1 hour) morning joint stiffness is less typical of osteoar –
thritis and should be discussed with a health professional.
Reduction in the normal range of motion within
the joint
As the condition causes more symptoms, the joint may become less movable
and eventually it may not be possible to fully straighten or bend it.
Tenderness
Joints affected by osteoarthritis may be tender to the touch, even in the
absence of obvious signs of inflammation.
Crepitus
The crunching, creaking, crackling, grating, or grinding sounds and sensation
on movement of the joint is called ‘crepitus’. The causes of these sensations
are unknown; they might be related to a roughening of the normally smooth
cartilage surfaces inside the joint.
Swelling
Later in the course of OA, swelling of the joint may develop. This can either be
soft in consistency (due to extra synovial fluid) or firm (due to bony enlarge –
ment at the joint—most commonly seen in the joints of the fingers).
The soft joint swelling from fluid is called an ‘effusion’. An effusion results
from the accumulation of excess fluid in the joint space. Potentially this swell –
ing will be warm, but if the joint is red or hot this is unusual for osteoarthritis
and you should have this checked by your doctor as it is more suggestive of
other conditions.
Bony growths called osteophytes or bone spurs commonly develop in the joints
at the ends or middle of the fingers (called then Heberden’s or Bouchard’s
nodes), among others. These bony protuberances can be felt under the skin
near joints, and typically enlarge over time.
Muscle weakness
In more advanced osteoarthritis, muscles may become weaker because
of insufficient use. In some joints (such as the knee), the ligaments, which

Osteoarthritis · facts
24surround and support the joint, stretch so that the joint becomes unstable.
This is one of the late signs of osteoarthritis one can potentially improve with
available therapies such as physiotherapy and exercise programmes.
Symptoms in specific joints
Osteoarthritis does not affect all joints equally. The condition most com –
monly affects the hand, knee, hip, and spine, but other joints can be affected
(Figure 3.1).
Furthermore, osteoarthritis often has an asymmetric pattern, affecting joints
on either side of the body to a different extent.
Figure 3.1 Common sites of pain in osteoarthritisSpin e
Hips
Finger s
Knees
FeetCommon pain
sites

chapter 3 · Symptoms and signs
25Knees
Osteoarthritis is particularly debilitating in the weight-bearing joints of the
knees. Osteoarthritis of the knees is often associated with obesity or a his –
tory of repeated injury and/or joint surgery. Advanced osteoarthritis of the
knee may be associated with changes in the alignment of the knee, including a
bow-legged or a knock-kneed appearance.
Osteoarthritis of the knee may also cause a Baker’s cyst, a collection of joint
fluid in the hollow at the back of the knee (Figure 3.2). The rupture of a Baker’s
cyst is usually painful and can be difficult to differentiate from a blood clot in
the leg (deep vein thrombosis).
Patients with osteoarthritis of the weight-bearing joints (like the knees) some –
times develop a limp, which can worsen as the joint degenerates. Although
painful, the arthritic knee usually retains reasonable flexibility. The pain of
knee osteoarthritis is often made worse during activities such as walking,
squatting, getting in or out of a chair, and climbing stairs.
Spine
Osteoarthritis may affect the cartilage in the discs that form cushions between
the bones of the spine (otherwise known as degenerative disc disease), the
moving joints of the spine itself, or both. Osteoarthritis typically affects the
most flexible regions of the spine, including the vertebrae (the individual Figure 3.2 A Baker’s cyst is seen as a swelling behind the knee. It forms when joint
fluid collects behind the knee. The swelling may be due to inflammation or from other
causes, such as arthritisBaker’s
cyst

Osteoarthritis · facts
26bones that make up the spine) in the lower neck, lower chest, and lower back.
Osteoarthritis in any of these locations can cause pain, muscle spasms, and
diminished mobility.
Osteoarthritis of the spine can lead to complications. Bony outgrowths of the ver –
tebrae in the lower spine may press on the nerves within the spinal canal, causing
low back pain and pain in the legs that is worsened by exercise, and also numb –
ness and tingling of the affected parts of the body. Osteoarthritis of the lower
spine may also cause the normally aligned vertebrae to slip out of alignment.
When the spine is affected in the neck, narrowing of the spinal canal can cause
damage to the spinal cord, resulting in arm or leg weakness, difficulty walking,
or loss of control of the bowel or bladder. Any of these complications can be
serious and you should seek medical attention if you suspect you have any of
these symptoms.
Hands
Osteoarthritis of the fingers occurs most often in older women and may be
inherited within families. Osteoarthritis causes the formation of hard bony
enlargements (nodes) of the small joints of the fingers. The characteristic
appearances of these finger nodes can be helpful in diagnosing osteoarthritis.
Osteoarthritis may cause enlargements of the last joints on the fingers (the
distal interphalangeal or DIP joints) called Heberden’s nodes. The bony
deformity is a result of the bone and cartilage spurs (osteophytes) from the
Figure 3.3 Bouchard’s and Heberden’s nodes
Heberden’s
nodes
Bouc hard ’s
nodes
Osteoart hritis
(late stage)

chapter 3 · Symptoms and signs
27osteoarthritis in that joint. Osteoarthritis may also cause enlargements of
the middle joints of the finger (the proximal interphalangeal or PIP joints)
called Bouchard’s nodes (Figure 3.3). Osteoarthritis also frequently dam –
ages the base of the thumb, which may give the hand a squared appearance.
Gelatinous cysts, which sometimes go away on their own, may also form in
the finger joints.
Hips
Osteoarthritis frequently strikes the weight-bearing joints in one or both hips.
Pain develops slowly, usually in the groin and on the outside of the hips, or
sometimes in the buttocks. The pain may also radiate to the knee, making the
diagnosis less clear. Those with osteoarthritis of the hip often have a restricted
range of motion (particularly when trying to rotate the hip) and walk with a
limp, because they slightly turn the affected leg to avoid pain. The pain of hip
osteoarthritis is often made worse during activities such as walking, getting in
and out of the car, and putting socks or stockings on.
Shoulder
Osteoarthritis is less common in the shoulder area than in other joints.
Osteoarthritis may cause vague shoulder discomfort, bony outgrowths that
irritate or even tear the surrounding tendons, and, occasionally, marked pain
and restriction of movement. It may develop in the shoulder joint itself (called
the glenohumeral joint). In such cases it is most often associated with a previ –
ous injury, and patients gradually develop pain and stiffness in the back of the
shoulder. Osteoarthritis also can develop in the joint between the shoulder
blade and the collarbone, the acromioclavicular (AC) joint.
Feet
Osteoarthritis often affects the feet. Inflammation of the joint at the base of
the big toe may cause a bunion or stiffness of the joint and may make it diffi –
cult to walk.

29There is no single sign, symptom, or test result that allows a definitive diag –
nosis of osteoarthritis. Instead, the diagnosis is based on a consideration of
several factors, including the presence of characteristic signs and symptoms
(described in Chapter 3 in greater detail) and where necessary the results of
X-rays and laboratory tests.
Medical history: symptoms and risk factors
A person’s medical history often suggests the presence of osteoarthritis. A
doctor will ask about the presence, duration, and pattern of joint symptoms,
and any other symptoms. A doctor will also ask about the effects of the symp –
toms on daily activities.
The usual symptom is pain involving one or only a few joints. Joint involve –
ment is often asymmetric—meaning that it can affect joints on either side of
the body to a different extent. Morning joint stiffness that usually resolves
within 30 minutes is also common. As the disease progresses, night pain, pro –
longed joint stiffness, and joint enlargement are evident. Crepitus, a grating
sensation in the joint, is a late symptom. Limitation of joint movement may be 4
How is osteoarthritis
diagnosed?
% Key points
◆ Osteoarthritis is a clinical diagnosis based on the symptoms and signs
you present with.
◆ X-rays can be helpful to confirm this diagnosis and where necessary
laboratory tests can help to rule out other conditions.
◆ Please seek help from a health professional to make the correct diagnosis.

Osteoarthritis · facts
30due to flexion contractures (inability to fully extend the joint) or mechanical
obstructions (joint locking).
Also the presence of common risk factors is helpful for the confirmation of a
diagnosis of osteoarthritis. Repeated work-related trauma, previous injury/ies
in the affected joint/s, overweight/obesity, and an age of over 40 years old are
typically related to osteoarthritis, and might help confirm a diagnosis.
Physical examination (signs)
The signs noted during a physical exam often support a diagnosis of osteo –
arthritis. OA’s usual expression involves multiple structures. Consequently,
medical diagnosis is most appropriately based upon careful clinical examina –
tion of overall joint function. During a physical exam, a doctor will check for
joint swelling, abnormalities in range of motion, tenderness, and bony out –
growths. He or she will also check for changes in joint alignment and a loss of
muscle mass around the joints.
Clinical examination for hip and/or knee OA should include an assessment of
body mass (because this risk factor is so important in predisposing to OA and
increasing the rate of progression once disease is evident) and postural align –
ment in both standing and walking.
Knee
Assessing knee alignment for the presence of genu varum (bow-legged)
or genu valgum (knock-kneed) malalignment is most easily seen when the
patient is asked to stand with their legs together. In the presence of genu val –
gum, the knees will touch and the feet will remain separated, while in the pres –
ence of genu varum, the feet will come together even while the knees remain
separated (Figure 4.1).
The barefoot standing posture of the feet should also be noted so that rec –
ommendations can be made for supportive footwear. The assessment of joint
range of motion, stability of the ligaments, muscle strength, and tenderness to
focal palpation constitutes a basic physical examination.
Clinical features that help to establish a diagnosis of symptomatic knee OA
include gradually developing local knee pain and stiffness, limited active and pas –
sive motion, intra-articular (inside the joint) swelling that reoccurs with activity,
crepitus, a past history of knee injury or arthroscopic (telescopic) surgery, focal
tenderness over the affected regions of the medial (inside) or lateral (outside)
joint margin, and advancing age. Knee OA is unusual in people younger than 40.

chapter 4 · How is osteoarthritis diagnosed?
31During the clinical examination, some attempt must be made to rule out
referred pain to the knee from the hip or lumbar spine. Sciatica (lumbar radic –
ulitis) is a common cause of posterior or lateral knee pain and should be ruled
out with a straight-leg raise test while you are lying flat on your back. Further
evaluation is indicated when the diagnosis remains uncertain, response to
therapy is not as expected, or significant clinical changes occur.
Hip
Hip pain and a limited internal rotation (usually less than 15ș), and/or pain on
hip internal rotation are the most common signs of hip osteoarthritis. Hip OA
is rare in people aged younger than 50 years old.
Hand
Bony enlargements affecting certain finger joints (Bouchard’s and Heberden’s
nodes) constitute a common sign of hand OA. Other joint deformities such as
malalignment can also be seen in a number of hand joints affected with OA.
X-rays
X-rays are a form of electromagnetic radiation (like light); they are of high –
er energy, however, and can penetrate the body to form an image on film. Figure 4.1 (a) The valgus deformity (knock-kneed); (b) the varus deformity (bow-
legged)(a) (b)Valgus
(kno ck-kneed )Varus
(bow-leg ged)

Osteoarthritis · facts
32Structures that are dense (such as bone) will appear white, air will be black,
and other structures will be shades of grey depending on their density.
X-rays may be helpful in confirming a diagnosis of OA, although there is often
a discrepancy between the severity of symptoms and the results of X-rays in
people with osteoarthritis. Radiographs are not required for every person who
presents with symptoms consistent with osteoarthritis. Patients whose clini –
cal history or course suggests other conditions should undergo radiographic
evaluation.
This includes patients with trauma, joint pain at night, progressive joint pain
(without prior radiography), significant family history of inflammatory arthri –
tis, and children younger than 18 years. Simple X-ray testing can be very help –
ful to exclude other causes of pain in a particular joint.
Bearing in mind that radiographs are notoriously insensitive to the earli –
est features of OA, the absence of positive radiographic findings should not
be interpreted as confirming the complete absence of symptomatic disease.
Conversely, the presence of positive radiographic findings does not guarantee
that an osteoarthritic joint is also the active source of the patient’s current
knee symptoms. Asymptomatic radiographic OA (presence of X-ray OA with –
out symptoms) is common, especially among older patients in whom radio –
graphic findings are also frequently present in multiple joints.
OA can occur in any joint of the body, but it is most common in the knees,
hips, low back, fingers, and at the base of the thumb. While techniques for
obtaining images may vary between different regions of the body, the radio –
graphic features of OA are similar (Figure 4.2). The following findings on
X-rays suggest the presence of osteoarthritis:
◆ Narrowing of the joint space (the space between the two bones), indicating
the loss of cartilage. This provides a useful indication of the location and
severity of OA, but it is not solely indicative of articular cartilage (cartilage
lining the end of the bones) loss. It can also reflect changes in alignment
and the meniscus.
◆ An abnormal hardening of the bone beneath the cartilage surface is termed
radio-opaque thickening or sclerosis.
◆ Bony outgrowths (osteophytes) appear characteristically at the joint mar –
gins as a result of new bone and cartilage/growth.
◆ The presence of cysts beneath the surface of the bone.

chapter 4 · How is osteoarthritis diagnosed?
33Laboratory tests
There is no laboratory test for the diagnosis of osteoarthritis. Laboratory tests
are useful to rule out other conditions with similar symptoms that can mimic
osteoarthritis:
◆ Erythrocyte sedimentation rate (ESR): the ESR does not specifically indi –
cate osteoarthritis. A high ESR may indicate that arthritis is being caused
by an inflammatory condition.
Figure 4.2 An X-ray taken from the front of the knee demonstrating narrowing of the
medial (inner) joint space, increased bony whiteness (sclerosis), and osteophytes (new
bone and cartilage) forming at the inner joint margin

Osteoarthritis · facts
34◆ Rheumatoid factor: an antibody called rheumatoid factor is present in most
people with rheumatoid arthritis and can help distinguish osteoarthritis
from rheumatoid arthritis.
◆ Synovial fluid analysis: small samples of synovial fluid (the fluid bathing the
joint) can be withdrawn and analysed during a procedure called arthro –
centesis. During arthrocentesis, a sterile needle is used to remove joint
fluid for further analysis. In people with osteoarthritis, this fluid is usually
clear and viscous and contains few inflammatory cells. The presence of
crystals in the fluid may be an indication of gout. Other abnormalities
such as an increased number of certain cells in the fluid can be suggestive
of other conditions. Removal of joint fluid and injection of corticosteroids
into the joints during arthrocentesis can help relieve pain, swelling, and
inflammation.
Other investigations
When the results of other tests are inconclusive, a doctor may recommend a
magnetic resonance imaging (MRI) scan or arthroscopy. It is important to
state that both are overused for diagnosis and typically don’t change the way
you are managed so given their costs and potential for risks it is important to
clearly determine whether this is necessary. In an arthroscopy, a thin lighted
tube is moved into the joint space, allowing direct inspection of the joint struc –
tures. Arthroscopy is especially useful for detecting damage of cartilage, which
is not visible on X-rays, and it can also be used for therapeutic interventions
such as the extraction of pieces of cartilage after a meniscal injury.
Diagnostic criteria
Formal criteria are helpful for diagnosing osteoarthritis in specific joints.
These are used in the clinical setting as well as in research to increase the
likelihood that a person has OA of either the knee, hand, or hip. What fol –
lows are the criteria developed and proposed by the American College of
Rheumatology (ACR, 1991), and a simplified version of the recommenda –
tions proposed by the European League Against Rheumatism (EULAR) for
the diagnosis of hand (2009) and knee OA (2010).
Osteoarthritis of the knee
ACR 1991 diagnostic criteria1
The ACR 1991 criteria for osteoarthritis of the knee include the presence of
knee pain plus at least three of the following:

chapter 4 · How is osteoarthritis diagnosed?
351. Age greater than 50 years.
2. Morning stiffness lasting less than 30 minutes.
3. Crackling or grating sensation (crepitus).
4. Bony tenderness of the knee.
5. Bony enlargement of the knee.
6. No detectable warmth of the joint to the touch.
Laboratory tests and X-rays are often used in addition to these criteria to
diagnose osteoarthritis of the knee.
EULAR 2010 (modified) recommendations for the diagnosis
of knee osteoarthritis2
1. Knee OA is characterized by usage-related pain and/or functional limitation.
2. Risk factors that are strongly associated with the incidence of knee OA can
help to diagnose knee OA. These include: increasing age over 50 years,
female gender, overweight/obesity, previous knee injury, join hypermobil –
ity, occupational or recreational usage, family history, and the presence of
Heberden’s nodes.
3. Typical symptoms of knee OA are: usage-related pain, often worse towards
the end of the day, relieved by rest; the feeling of ‘giving way’, and only
mild morning or inactivity stiffness. Please note that more persistent rest
and night pain may occur in advanced knee OA.
4. In adults aged over 40 years with usage-related knee pain, only short-lived
morning stiffness, functional limitation, and typical examination findings
(crepitus, restricted movement, bony enlargement), a confident diagnosis
of knee OA can be made without a radiographic examination. This applies
even if radiographs appear normal.
5. Typical signs and symptoms indicative of knee OA include: crepitus, pain –
ful and/or restricted movement, bony enlargement, and absent or modest
effusion.
6. Plain radiography is the current ‘gold standard’ for the morphological
assessment of knee OA. Further imaging (e.g. MRI or computed tomog –
raphy (CT) scans) are seldom indicated for diagnosis of knee OA.

Osteoarthritis · facts
367. Laboratory tests are not required for the diagnosis of knee OA, but may be
used to rule out other diseases.
Osteoarthritis of the hand
ACR 1991 diagnostic criteria3
The criteria for osteoarthritis of the hand include the presence of hand pain
plus at least three of the following:
1. Bony enlargement of at least two or more of ten selected joints.
2. Bony enlargements of two or more distal interphalangeal (DIP (joints at
the end of the fingers)) joints.
3. Fewer than three swollen metacarpophalangeal (MCP (knuckle)) joints.
4. Deformity of at least one of the ten selected joints.
5. Osteoarthritis of the hand can often be diagnosed on the basis of these
criteria alone, and laboratory tests and X-rays may be unnecessary.
EULAR 2009 (modified) recommendations for the diagnosis
of hand osteoarthritis4
1. Risk factors for hand OA include: female sex, increasing age over 40, men –
opausal status, family history, obesity, higher bone density, greater fore –
arm muscle strength, joint hypermobility, prior hand injury, and occupa –
tion or recreation-related usage.
2. Typical symptoms of hand OA are: pain on usage and only mild morning
stiffness, involvement of just one or a few joints at any one time; symptoms
are often intermittent and target characteristic sites (Figure 4.3). With
such typical features, a confident clinical diagnosis can be made in adults
aged over 40 years.
3. Typical signs of hand OA are: Heberden’s and Bouchard’s nodes and/or
bony enlargement with or without deformity affecting characteristic joints
(Figure 4.3).
4. Patients with hand OA are at an increased risk of hip and knee OA, and
should be assessed and examined accordingly.
5. Three subtypes of hand OA are recognized: (1) interphalangeal (small
joints within the fingers) OA, (2) thumb base OA, and (3) erosive hand OA.

chapter 4 · How is osteoarthritis diagnosed?
376. Erosive hand OA is characterized by the following: targets interphalangeal
joints; shows erosions in plain X-ray; typically has an abrupt onset, with
marked pain and inflammation; usually has a worse prognosis than non-
erosive hand OA.
7. Plain X-rays provide the gold standard for morphological assessment of
hand OA.
8. Blood tests are not required for the diagnosis of hand OA but may be used
to rule out other conditions such as rheumatoid arthritis.
Osteoarthritis of the hip5
The diagnosis of osteoarthritis of the hip relies on the results of laboratory
tests and X-rays. The criteria for osteoarthritis of the hip include the presence
of hip pain plus at least two of the following:
1. A normal ESR.
2. The presence of bony outgrowths (osteophytes) on X-rays.
3. The presence of narrowing in the joint space on X-rays, indicating a loss
of cartilage.Figure 4.3 Nodular swelling of the DIP and PIP joints (small joints at the ends and
middle of the fingers) of the hand consistent with osteoarthritis

Osteoarthritis · facts
38Conclusion
Osteoarthritis is a clinical diagnosis based on the symptoms and signs you
present with. X-rays can be helpful to confirm this diagnosis and where neces –
sary laboratory tests can help to rule out other conditions. Please seek help from
a health professional to make the correct diagnosis and do not use this chapter for
making your own diagnosis.
References
1. Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. The American
College of Rheumatology criteria for the classification and reporting of osteoarthritis of
the knee. Arthritis and Rheumatism 1986; 29:1039–1049.
2. Zhang W, Doherty M, Peat G, Bierma-Zeinstra MA, Arden NK, Bresnihan B, et al.
EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis.
Annals of the Rheumatic Diseases 2010; 69(3):483–489.
3. Altman R, Alarcón G, Appelrouth D, Bloch D, Borenstein D, Brandt K, et al. The
American College of Rheumatology criteria for the classification and reporting of
osteoarthritis of the hand. Arthritis and Rheumatism 1990; 33:1601–1610.
4. Zhang W, Doherty M, Leeb BF, Alekseeva L, Arden NK, Bijlsma JW, et al. EULAR
evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a
task force of ESCISIT. Annals of the Rheumatic Diseases 2009; 68(1):8–17.
5. Altman R, Alarcón G, Appelrouth D, Bloch D, Borenstein D, Brandt K, et al. The
American College of Rheumatology criteria for the classification and reporting of
osteoarthritis of the hip. Arthritis and Rheumatism 1991; 34:505–514.

395
The outlook or prognosis
% Key points
◆ Research has helped us to understand the natural course of
osteoarthritis.
◆ Y our osteoarthritis will not necessarily get worse, it can remain stable
and even improve with time.
◆ Being overweight is a strong risk factor for the worsening of osteoar –
thritis and its symptoms.
◆ It is helpful to have a good understanding of factors that can cause
osteoarthritis to progress to enable us to develop a management plan.
This will include a number of things that can be done at home without
the need for medical input.
# Frequently asked questions (FAQ)
Like many other chronic conditions, people who have been diagnosed
with osteoarthritis like to know what the natural course of the disease is.
Questions such as: will it deteriorate? Will it affect every joint? Will I need
a joint replacement? are commonly asked.
In practice, doctors treat patients with varying degrees of osteoarthritis:
at one end of the spectrum are those with very mild symptoms and just
one joint affected, while at the other end of the scale are those with severe
progressive osteoarthritis and multiple joint involvement. The answers to
these common questions are therefore not black and white, as the natural
course of osteoarthritis can vary considerably between individuals.

Osteoarthritis · facts
40Research and osteoarthritis progression
Research plays a vital role in helping us learn more regarding the natural pro –
gression of osteoarthritis. Over the past two to three decades there have been
studies both in Europe and in America that have followed patients for periods
ranging from 2 to 15 years with the aim of establishing the natural progression
of osteoarthritis to see if there are any familiar patterns to the disease process.
This research has examined the disease progression in the most common sites
affected by osteoarthritis—the knee, the hip, and the hand—and has mainly
concentrated on the following signs and symptoms:
◆ The amount of pain and discomfort and the loss of function experienced.
◆ The X-ray changes that show a loss of articular cartilage, the presence of
osteophytes, and occasionally sclerosis of the bone.
◆ Pathological changes to the bone and cartilage structure and the other
components of the joint.
Having these three main areas of focus makes the research projects more com –
plex, especially as we already know from previous chapters that the amount of
pain does not always correlate with the amount of deterioration of joint struc –
ture and vice versa. The results of research to date have, however, identified
three conclusions regarding the natural progression of OA:
1. There are some general factors that can influence the progression of OA
for individuals.
2. Each joint has a different natural progression.
3. Not all joints affected by OA will progress.
General factors affecting the progression
of osteoarthritis
There have been several general factors associated with the progression of OA
in the joints in general. Some of them are intrinsic and others are extrinsic;
that is, some are due to our genetic make-up while others are influenced by
environmental factors such as obesity, muscle weakness, and injury. These fac –
tors are taken into consideration when trying to ascertain the course of OA in
an individual. Fortunately it is possible to make some positive changes with
some of the environmental factors mentioned and these in turn can alter the
progression of osteoarthritis.

chapter 5 · The outlook or prognosis
41Age
Unfortunately we are unable to stop the body clock, and the older we become
the more susceptible we are to developing osteoarthritis, so much so that by
the age of 75 years it is estimated 90 per cent of us will develop osteoarthritis
that is visible on X-ray in at least one joint, although not all of us will develop
symptoms. However, older ages are also associated with an increased risk of
developing persistent pain.
Multiple joint involvement
There is good news, however. If you have osteoarthritis of one joint you will
not automatically develop osteoarthritis in your other joints, indeed many of
us will know a friend or colleague who has osteoarthritis of just one joint.
However, research has demonstrated that if two or more joints are involved
with osteoarthritis there is a greater risk of the disease progressing within a
joint. This has been demonstrated in studies of the knee and the hip where
there is more disease progression when another joint has osteoarthritis. For
instance, the presence of Heberden’s nodes on the fingers (see later ‘Hand’
section) can increase the progression of knee osteoarthritis up to sixfold. This
increased risk is also present if two of the same type of joint are affected, for
example, bilateral (both) knee osteoarthritis has been found to be more likely
to progress than unilateral (one) knee osteoarthritis.
Moreover, the presence of hand or knee osteoarthritis has been related to an
increased risk of developing symptomatic hip OA; similarly, a history of hand
or hip osteoarthritis is associated with a higher risk of symptomatic knee OA.
Obesity
We are already aware that being overweight is a major contribution to the ini –
tial onset of osteoarthritis of the weight-bearing joints, knee and hip, and also
of the hand, especially in women. Research has also shown that obesity has a
very strong link to the progression of osteoarthritis in these joints.
The mechanisms behind the progression of the disease in those who are over –
weight is due first to excessive loading upon the joints through daily activity,
which in turn causes breakdown of some cartilage and also puts huge stress on
other structures of the joint; and second, is due to metabolic factors. In those
who are overweight it is thought that abnormal cholesterol levels and glucose
circulating in the blood, along with chronic inflammation, can affect the pro –
gression of osteoarthritis: this is why the disease develops in non-weight-bearing

Osteoarthritis · facts
42joints such as those of the hand. Fortunately studies have shown that it is possi –
ble to reduce the progression of osteoarthritis by losing weight through chang –
ing diets and lifestyles—Part 2 (Chapter 8) of this book will discuss this in
more detail.
Muscle weakness and joint injury
Chapter 2 discussed the importance of muscle strength and tone in helping
to maintain what is termed ‘a stable joint’: one that will ensure it moves in
the correct direction with good power. In a good joint all the structures work
together to maintain this stability. Studies have shown that previous injuries to
joints and poor muscle strength are factors that can accelerate osteoarthritis
progression. Unfortunately surgical correction following an injury does not
completely protect the joint from osteoarthritis in the future.
Although limited data is available, there is some evidence that protecting our
joints and muscles prior to exercising by gentle stretching and warming up
and cooling down are now routinely practised in schools, colleges, and at exer –
cise classes, and will help reduce injuries that will prevent the onset of osteoar –
thritis of that specific joint in the long term. Muscle strength can be improved
to prevent progression, and Part 2 of this book will cover it in more detail.
Specific joints and the progression
of osteoarthritis
Most research to date has focused on the knee, the hip, and the hand. Although
other sites are discussed in the following sections, there is far less research
with which to correctly identify specific natural progression.
Knee
The knee is one of the more complex joints of the musculoskeletal system:
it has three compartments, all of which can develop osteoarthritis. In gen –
eral, research has shown that the progression of knee osteoarthritis is often
very slow, often taking years to develop and remaining stable for several years.
Recent data from a healthy group of women followed for 15 years in the UK
have provided us with detailed information on the occurrence and progression
of knee osteoarthritis: as it can be seen in Figure 5.1, about one in five people
with knee osteoarthritis experience worsening of the X-ray changes of OA. On
the other hand, the good news is that this is not always symptomatic: in the
same UK population, fewer than 1 in 10 people with knee pain have persistent
pain in the same joint.

chapter 5 · The outlook or prognosis
43Those who have experienced a significant knee injury tend to develop osteo –
arthritis of this joint at an earlier age, the disease developing up to 20 years
earlier than if no injury were sustained. Unfortunately the knee joint is prone
to injury due to its complexity as a joint and also due to its function. In gen –
eral it is thought that the rate of progression is accelerated by continued heavy
weight-bearing activities and repetitive movements such as kneeling. Excess
body weight also accelerates the disease process, as mentioned earlier.
Those who have osteoarthritis with altered alignment such as valgus or varus
alignment (commonly called knock-knees or bow-legs) experience osteoar –
thritis of this joint five times more often than those who have neither abnor –
mality. This occurs as a result of excessive uneven loading of weight within
the joint progression, which leads to premature stresses on the other joint
structures (Figures 5.2 and 5.3).
Initially the symptoms of pain and stiffness are treated with analgesics and
physiotherapy, which enable normal activity levels, but as the disease pro –
gresses people experience more pain and difficulties performing daily activi –
ties such as walking, climbing stairs, or climbing in and out of the bath. Over
time the knee joint stiffness and swelling increases in 55 per cent of people,
which often leads to less activity.Figure 5.1 Prevalence (% affected) and progression (worsening of radiographic
severity) of knee osteoarthritis after 15 years of follow-up in the Chingford cohort, UK
Source: data from Leyland KM et al., The Natural History of Radiographic Knee Osteoarthritis: A
Fourteen-Year Population-Based Cohort Study, Arthritis and Rheumatism , Volume 64, Number 7,
pp. 2243–2251, Copyright © 2012, American College of Rheumatology
60
% Knee OA% worsening5040302010
0
0 51
01 5

Osteoarthritis · facts
44Figure 5.2 (a) The valgus deformity (knock-knees) showing the uneven pressure on
the knee joint; (b) the varus deformity (bow-legged) showing the uneven pressure on
the knee jointValgus
(kno ck-kneed )
(a) (b)Varus
(bow-le gged)
Figure 5.3 How common the involvement of each joint of the hand is for men and
women with osteoarthritis of the hand
Fema le
70%
35%
10%
60%
5% 20%40%20%35%70%Male
Metacarp o-
phalangeal
joints
/T_humb bas e
WristJoint site
Distal
interphalangeal
joints
Proximal
interphalangeal
joints
The longer studies that followed patients for 11–15 years with X-rays have
shown that between 33 to 66 per cent of subjects who have OA of the knee
displayed worsening of the disease as measured by further loss of cartilage.
Over the years scientists have studied X-rays to ascertain if the presence of any

chapter 5 · The outlook or prognosis
45one specific feature such as osteophytes, sclerosis, and joint space narrowing
can determine the course that the OA will take, and they concluded that all
the features are important determinants of OA progression of this joint.
Hip
There has been less research into the natural course of OA of the hip joint,
partly because it is thought people do not visit their clinician until they are
in the late stages of the disease. However, it is suggested that the progression
in this joint is more rapid and aggressive than the knee joint, often ranging
from 3 months to 3 years before seeking surgery. Two studies have shown that
for a small number of people the symptoms and sometimes the radiological
changes can improve, but they are the minority. As the hip is a weight-bearing
joint its acceleration is affected by excessive loading of weight, either through
an increase in body weight or through heavy manual work. For those who
have been born with congenital hip abnormalities the onset of OA in this joint
starts earlier at approximately 40 years of age.
It has been recently shown that certain anatomical abnormalities are highly
correlated with the development of hip OA. The so-called ‘cam impingement’
(Figure 5.4) relates to a bump on the upper portion of the femur head. It has
been associated with an increased rate of hip OA and even with an increased
risk of total hip replacement for severe hip OA.
Initially the pain is controlled with analgesics and many people find using
a walking stick beneficial. As the disease progresses, the pain when walking
increases, night-time pain can develop, and up to 60 per cent of people seek
surgical treatment following 2 years from initial diagnosis. One complication
of hip OA is the death of bone tissue (osteonecrosis), which tends to occur in
the late stages of its progression. This would necessitate surgery.
Hand
OA of the hand usually affects the distal phalangeal joint (DIP) and the proxi –
mal phalangeal joint (PIP) joint of the fingers and also the base of the thumb
and is common with women in their 50s. The natural history of OA in the fin –
gers is very different than that of the knee and hip joints. It starts with a general
ache in the affected joint, which comes and goes, followed by an inflammatory
phase where the joints can become swollen and tender. During this phase,
which often lasts 1 to 2 years, Heberden’s and Bouchard’s nodes develop:
these are initially firm but later become hard and bony. After several years the
pain and tenderness subside but the swellings become firm and fixed, result –
ing in reduced movement. Often during the seventh and eighth decade the
symptoms in the joints settle, but the nodes and deformities usually remain.

Osteoarthritis · facts
46Many people are anxious regarding the appearance of these but they rarely
progress to the point where a joint replacement is necessary and at this stage,
despite some stiffness, are often free of pain.
The base of the thumb can also develop OA and initially becomes painful
when writing or using a keyboard. As with OA of the fingers mentioned pre –
viously, the symptoms are initially treated with analgesics and non-steroidal
anti-inflammatory drugs (NSAIDs). For some people OA of the thumb base
necessitates splints, injections and occasionally surgery.
Shoulder
This joint is less commonly affected by OA and there has been little research
into it with regard to OA progression. Often OA of the shoulder has developed Figure 5.4 Illustration of the ‘cam impingement’
Adapted by permission from Macmillan Publishers Ltd: Nature Reviews Rheumatology , Rintje
Agricola et al., Cam impingement of the hip—a risk factor for hip osteoarthritis, Volume 9, Issue 10,
pp. 630–634, Copyright © 2013Normal
a
Cam
b
*
αα

chapter 5 · The outlook or prognosis
47as a consequence of trauma. If conservative treatment of analgesia and
NSAIDs fail to relieve symptoms or improve function then surgery is consid –
ered, although a full range of movement is not always achieved following this.
Foot
Although OA can occur in any joint of the foot it is the big toe joint that is
most commonly affected. Wearing well-fitting shoes often relieves pain, and
orthotics is also helpful for some people. Generally people manage OA in this
joint using analgesics and non-steroidal anti-inflammatories, although a small
proportion are referred for surgical treatment if symptoms continue to be
troublesome.
Spine
Osteoarthritis of the spine is often over-diagnosed by many people who incor –
rectly label disc degeneration or simple mechanical back pain as being arthrit –
ic. OA of the spine only affects the facet joints and its course is one of a natu –
ral progression over many years, sometimes causing flare-ups of pain along the
way. Although spinal pain is common in the general population there has been
little research into the progression of facet joint OA.
Conclusion
Previous studies have shown that progression of OA varies between each type
of joint and can be influenced by several factors, some of which are intrinsic
while others are environmental. For these reasons the natural course of OA
can vary enormously between individuals and not everyone develops wide –
spread OA requiring surgery.
To some degree it is up to individuals and choices that they make as to how the
disease progresses, and how they choose to manage it, can alter the progression
and symptoms of OA.
Unfortunately there is no cure at present for OA, but research continues to
play a vital role in enabling us to understand the disease process in more
detail, which in turn will help us to treat it effectively and slow its natural
progression.

49Part 2
Management
of osteoarthritis

51Our intent in writing this book is to produce a patient-friendly resource that
could provide the interested person who has osteoarthritis with information to
help them to manage their osteoarthritis. We hope this book will expand your
knowledge of OA and help with your own disease management.
Osteoarthritis is a disease of the whole joint. It can cause pain and inflam –
mation, and stiffness that often lead to reduced function. This can affect us
in many different ways. It can impact on our work, our home life, and on our
leisure time and can affect our moods and emotions. We are all individuals and
for some people with osteoarthritis everyday tasks such as washing, dressing,
cooking, and shopping can become difficult tasks to complete and for some 6
The management
of osteoarthritis—
an overview
% Key points
◆ There are a number of strategies that are helpful in the management of
osteoarthritis.
◆ First-line treatment for osteoarthritis should consist of conservative,
non-medication management and can be successful for mild to mod –
erate pain experienced with osteoarthritis.
◆ Only when these more conservative efforts fail to improve function or
reduce pain to an acceptable level should pharmaceuticals be offered.
◆ Surgery should be considered only once the other steps have been
tried.

Osteoarthritis · facts
52people thoughts and emotions can become unhelpful. Therefore although
osteoarthritis is a disease of the joint, it can have consequences that impact
greatly on our lifestyles. For this reason, when considering the management
for osteoarthritis, it is important to assess each person individually so as to
ensure that the areas of our lives that are affected by osteoarthritis can be
addressed.
Like other chronic diseases, there is no sole treatment or cure, instead there
are several strategies to use that can help manage the condition. Similarly peo –
ple who have diabetes are urged not to just take their insulin, but also to
reduce weight if overweight, to have a healthy diet, to monitor their blood
sugar levels, etc. All these strategies help maintain a safe blood sugar level and
improve good health, which can reduce the risk of developing complications.
Clinicians who manage patients with osteoarthritis recognize that to maxi –
mize treatments, it is best to use them as part of a package and incorporate
many of the strategies together. For instance, do not just take pain medicines
to manage your symptoms, but consider your weight, your fitness levels and
muscle strength, and evaluate your daily patterns of activity—are you pushing
yourself?
In America, guidelines have been written to address the treatment for osteo –
arthritis by the American College of Rheumatology (ACR), in Europe these
guidelines have been written by the European league against Rheumatism
(EULAR), and at an international level by the Osteoarthritis Research Society
International (OARSI) using the evidence from trials and from expert advice.
Although they differ slightly, the advice regarding treatment are similar with
the broad aims of:
1. Offering information about both the disease and its management.
2. Helping to control your pain.
3. To identify difficulties and help improve the function and decrease
disability.
4. Altering the disease process (slowing or minimizing progression) and its
consequences where possible.
The fourth of these aims, ‘to alter the disease process and its consequences’,
is aimed at altering the underlying structures in the joint that are affected in
OA with the intent to reduce the long-term morbidity associated with osteo –
arthritis. Of the four aims it is often the most difficult to achieve but the most
meaningful of them if you can.

chapter 6 · The management of osteoarthritis—an overview
53Broadly speaking, altering the disease process can be done in one of two ways:
1. The first is to modify one of the risk factors known to be associated with
the progression of disease. This includes modifying risk factors such as
body weight, joint alignment, and muscle strength. For example, if you are
overweight, losing weight will slow the progression of structural changes
within your joint. If your joint is malaligned, using treatments aimed at
improving alignment such as braces or shoes could alter long-term struc –
tural progression of the disease. Similarly if you have muscle weakness
or joint instability then improving muscle strength may impact upon the
structural course of your osteoarthritis.
2. The second is to take an agent/medication that may modify the underly –
ing structure of your joint. At this point it is difficult to make any strong
recommendations for the patient with osteoarthritis but definitely watch
this space. There is some provisional evidence that chondroitin sulphate
and strontium ranelate may fulfil this purpose.
These general aims are not in any order of importance and ideally all should
be addressed in some form. Where they are not being addressed by your
health professional it is important that you arm yourself with some knowledge
(such as that contained within this book) so that you can attempt to institute
some more self-management strategies or so you can ask your caring health
professional about them.
What forms of treatments are available?
The forms of conventional treatment strategies that are available today
include some educational groups, diet, exercise, pain management groups,
pain-relieving medications, medications with a potential to slow down pro –
gression, supplements, physiotherapy, injections, and surgery. But what treat –
ment should be tried first? It may not be appropriate, for instance, for people
to seek a surgical opinion as the first line of treatment as surgery is not usu –
ally indicated for most people who have osteoarthritis! With the knowledge
of treatments available, clinicians may follow the steps shown in Figure 6.1.
As you will see, the first stages of treatment address non-invasive treatments.
For many people with osteoarthritis these two steps alone will be sufficient to
manage the condition and prevent its progression and they should always be
tried first before moving onto steps three and four.
These treatments are discussed more fully in the following chapters of this
book.

Osteoarthritis · facts
54Step one: non-pharmacological approach
Education
OA is a chronic condition for which self-management plays a very important
role. Everyone with osteoarthritis should be encouraged to participate in avail –
able self-management programmes (such as those conducted by the Arthritis
Foundation). These programmes provide information regarding the natural
history of OA, and provide resources for social support and instruction on
coping skills as well as reducing anxieties that many people can have when
first diagnosed with osteoarthritis. They have been shown to have a mean –
ingful and longstanding impact on osteoarthritis management for individu –
als with this disease. For those who do not have access to such programmes,
medical centres, charities, physiotherapists, and clinicians may be able to offer
leaflets and literature regarding osteoarthritis and some physiotherapists run
osteoarthritis education groups. Further information can also be obtained via
the Internet (addresses included in Appendix 2). The more information you
have regarding the condition, the easier you will be able to manage the dis –
ease. It is hoped this book will be of great value here.
Weight loss
Anyone who is overweight with hip and knee OA should be encouraged to
lose weight through a combination of diet and exercise: overweight does not
only have an impact on your risk of developing OA, but also on progression
to severe disease stages and need for joint replacement among those who have
already been diagnosed with OA. The Arthritis, Diet, and Activity Promotion
trial (an 18-month study) showed that diet and exercise leads to overall
Non-pharmacologi c
mana gement
Educ ation, exerci se,
weight loss ,
appr opriat e
footwear
Mild
Symptom severitySeverePharmacologi c
mana gement
If ef fusion is
present aspirat e
and injec tNSAI DS, opioid sSurger y
Osteotomy,
total join t
replacemen tFurther non-
pharmacologi c
mana gement
Simple analgesics:Physiotherapy ,
braces
para cetamo l
Figure 6.1 Stepwise algorithm for the management of the patient with OA. This is
an example of a treatment algorithm that is modified according to your response
and the clinician’s preference. It highlights the encompassing need to consider non-
pharmacological management as first-line treatment for all persons with osteoarthritis

chapter 6 · The management of osteoarthritis—an overview
55improvements in self-reported measures of pain and function in older over –
weight and obese adults with knee OA (see Chapter 8).
Appropriate supportive footwear
This should be worn by anyone with osteoarthritis in the lower limbs. There
are a number of ways in which footwear can potentially modify impact loading
through the lower limb and thus reduce impact that potentially may lead to
pain if you have OA in the knee or hip. Shoes should be supportive and have
a low heel (even a heel 1.5 inches high can cause greater strain on the knee
joint). Many people with knee pain gain relief with customized orthotic inserts
and supportive shoes. For those with knee pain, a supportive running shoe
may assist in providing needed protection and thus reducing the symptoms
associated with knee OA.
Step two: further non-pharmacological treatments
Exercise
Exercise increases aerobic capacity, muscle strength and endurance, and also
facilitates weight loss. Quadriceps strengthening exercises have been demon –
strated to lead to improvements in pain and function (see Chapter 7 for more
details).
Canes
Perhaps the simplest way to reduce mechanical stress on a sensitive knee or
hip is to use a cane. In order to provide maximal benefit, the cane should be
held contralaterally (in the hand on the opposite side to the painful limb) and
put firmly to the ground with each footfall of the symptomatic side.
Step three: pharmacological therapies
Simple over-the-counter pain relievers (analgesics)
Paracetamol (acetaminophen) is the oral analgesic of choice for mild-to-moderate
pain in osteoarthritis. It reduces pain and is well tolerated at the recommended
dose (up to 3.2 g/day) and as such is often recommended as the first analgesic to
try by most physicians involved in the management of patients with osteoarthritis.
Vitamins and supplements
There are a number of supplements and vitamins marketed for the treat –
ment of osteoarthritis. The best known of these are glucosamine sulphate and

Osteoarthritis · facts
56chondroitin sulphate. They are generally very well tolerated, may reduce pain
and may slow the progression of the OA (see Chapter 10 for further details).
Pain-relieving medicines (analgesics)
◆ Non-steroidal anti-inflammatory drugs (NSAIDs) can be considered for
those who respond inadequately to paracetamol. However, there are cer –
tain disadvantages of routinely using NSAIDs in OA (see Chapter 10).
◆ Opioid analgesics are useful alternatives in patients in whom NSAIDs are
contraindicated, ineffective and/or poorly tolerated.
◆ Topical formulations of NSAIDs.
◆ Other medicines include duloxetine, amitriptyline, and capsaicin (see
Chapter 10 for further details).
Intra-articular injections
Injections into the joint may lead to considerable relief of pain in joints with
osteoarthritis. There are two different types of injections: corticosteroids and
hyaluronans. They need to be administered by a clinician and should be dis –
cussed with your doctor (see Chapter 10 for further details).
Step four: surgery
Surgery should be resisted when symptoms can be managed by other treat –
ment modalities mentioned in steps one, two, and three. The typical indica –
tions for surgery are debilitating pain and major limitation of functions such
as walking and daily activities, or impaired ability to sleep or work.
Different surgical interventions include:
◆ Arthroscopic debridement and lavage
◆ Osteotomy
◆ Joint replacement (see Chapter 12 for further details).
Future treatments for osteoarthritis
The reason for developing OA appears to be the result of a complex inter –
play between mechanical (increased pressure on selected parts of the joint),

chapter 6 · The management of osteoarthritis—an overview
57cellular (related to cells), and biochemical forces. Of these factors, mechani –
cal forces are paramount (Figure 6.2). Although osteoarthritis is a condition
associated with ‘getting old’ it should not be assumed that we can do little
about its occurrence. In the field of osteoarthritis, clinicians and scientists are
working hard to ascertain more about the disease process so as to improve
treatments, prevent progression, and also the onset.
Given the strong evidence for mechanical (see Figure 6.2) forces playing such
a prominent role in the development of osteoarthritis there have been few
therapies to date developed to address this issue. Pharmacological treatments
to date have focused on reducing inflammation (e.g. NSAIDs), and stimulat –
ing cartilage cell (chondrocyte) function and replenishing the lubricant found
to be lacking in the joint with osteoarthritis (hyaluronans). It could be argued
that unless the extra forces on the joint are not addressed then the medicines
will be limited in their effectiveness.
Figure 6.2 The mechanical axis of the knee is a line extending from the centre of the
hip joint to the middle of the ankle joint. This line is practically perpendicular to the
ground. In a healthy, well-aligned knee joint, the mechanical axis passes closer to the
middle of the knee. This allows for the stresses on the knee joint surfaces to be more
uniform in all areas of the joint and well balanced. In OA, the mechanical axis is often
disturbed. This disturbance results in the overload of distinct areas of the knee joint
leading to their damageNormal
kneeArthriti c
knee
NormalmechanicalaxisAxisout
of cent re
Worn ou t
cartilageNormalcartilage

Osteoarthritis · facts
58Knee braces and orthotics
Despite knowing for many years that altering loads in individuals with knee OA
is effective at relieving symptoms, use of therapies based on this principle are
limited. Despite being both efficacious and safe, knee braces (see Figure 6.3) are
not commonly prescribed in the management of knee osteoarthritis, and when
they are, their use declines rapidly with time. Knee OA is a chronic disease,
requiring long-term therapy, and while brace use has demonstrated improve –
ment in symptoms of pain and function in short-term studies (none longer than
6 months), there have been no long-term controlled studies that have evaluated
brace efficacy or adherence. Further longer-term studies are needed and ideally
with newer brace designs that are less cumbersome and bulky, thus facilitating
continued use.
Tissue engineering
Another area that demonstrates great potential but again needs further
research work to support its use before widespread use in persons with OA
is tissue engineering (see Figure 6.4). Tissue engineering, a term that was
coined in 1986, describes the science of replacing, repairing, or regenerat –
ing organs or tissue. The term is often used interchangeably with regenera –
tive medicine. In the field of osteoarthritis management, this includes the use
of growth factors to regenerate cartilage and bone, using new technologies
to enhance the healing of menisci and ligaments, efforts to produce tissue-
engineered cartilage, and the possibility of use stem cells derived from muscle
or fat to improve cartilage or bone healing. These advances could in the future Figure 6.3 Typical double-hinged knee brace for knee OA

chapter 6 · The management of osteoarthritis—an overview
59provide better treatment alternatives that may be termed biological replace –
ment. Currently one of the major limitations is that unless the mechanics of
the joint are also addressed, these have little opportunity of success.
Obesity—a concern for the future
From a public health perspective we could prevent approximately 50 per cent
of OA if we were able to stop the obesity epidemic. Measures to control weight
are essential if we are to make any public health impact on the prevalence of
this burdensome disease.
Joint injury
Sport injuries are the leading cause of injury hospitalizations and emergency
department presentations in children and young people. Rupture of the ante –
rior cruciate ligament (ACL) is among the most frequent and morbid muscu –
loskeletal injuries affecting physically active men and women. This injury has
Figure 6.4 Approaches to tissue engineering. Approaches include using biomaterials
(scaffolds) to hold and recruit cells and promote regeneration. Cells can also be used to
form tissues. Finally, growth factors (typically involved in the development of the joint)
can also be used to facilitate tissue regeneration

Osteoarthritis · facts
60implications for an injured person’s quality of life, their risk for OA, and long-
term disability. Numerous trials of neuromuscular conditioning programmes
have demonstrated efficacy in reducing the risk of ACL injury by as much
as 60 per cent. These programmes are simple and have impact; they typi –
cally consist of a warm-up, stretching, strengthening, plyometrics, and sport-
specific agility training. These programmes have generated widespread sup –
port from eminent international organizations including the IOC and FIFA.
Despite the impact of joint injury and the known efficacy of these prevention
trials, programme dissemination and implementation has been limited.
Altering the disease process
Several pharmacological agents including doxycycline and diacerein have
demonstrated their ability to modify structure but are unlikely to be widely
used for osteoarthritis for a number of different reasons, including costs, side
effects, and relatively limited benefit. Glucosamine and chondroitin sulphate
may also modify structure within the joint and are already in common use.
However, many major pharmaceutical and biotechnology companies have
products in their development pipeline with the intent of altering the disease
process. As yet their efficacy remains to be proven.
Greater attention to the important role of mechanical factors in OA develop –
ment is required if we are to find ways of reducing the public health impact
of this condition. Further research investigating weight reduction strategies,
mechanical therapies such as braces, and tissue engineering are greatly need –
ed. In time it may become apparent that rational treatment is a combination
of these interventions.
Conclusion
There are several strategies that are helpful in the management of osteoarthri –
tis. Some of the interventions are conservative and non-invasive as in step one
and two and can be successful for mild-to-moderate pain experienced with
osteoarthritis. Only when these more conservative efforts fail to improve func –
tion or reduce pain to an acceptable level should pharmaceuticals be offered
in steps three and four. Surgery should be considered only once the other
steps have been tried.
As with most chronic diseases the more information the person has about the
condition, the more in control they feel. It is hoped that Part 1 of this book has
explained the mechanisms of osteoarthritis which will enable you understand
the treatments available and how they can be helpful.

chapter 6 · The management of osteoarthritis—an overview
61Mrs V was a 67-year-old married woman who lived at home with her hus –
band of 40 years. They had three children and six grandchildren whom
they adored. When Mrs V was younger she worked at the railway station as
a clerk riding to and from her place of work by bicycle for 15 years until
she had a fall; after this she caught the bus instead.
Life had always been very busy as it often is with a large family, but it had
been a happy and joyous time. In her spare time Mrs V was a keen tennis
player and enjoyed walking holidays with her family. At home she was the
one in charge of the household. Housework was always top of her agenda
as she could not abide an untidy home. Her mother too had been very
house proud, and was known for washing the kitchen floor twice a day!
Mrs V retired from the railway at the age of 60 and was looking forward to
her retirement with her husband who was in good health. Mrs V too was in
good health, although for the past few years had developed some intermit –
tent pain and stiffness in her fingers which she put down to ‘all that house
work’. They had made many plans on paper as to how to spend their time
together which was to include a holiday to see the Swiss Alps, play at the
tennis club, help with the grandchildren, join the local art club, plus lots
of gardening and of course walking the dog on long forest walks. Life was
going to be enjoyed and full of activity.
Unfortunately not long after her last day at work, she developed some
knee pain when she was walking the dog round the forest. Initially she
thought nothing of it, believing that it would go away and after a day or
two of not walking the dog the pain did seem to settle until she came to
walk the dog again and it reoccurred. This time the pain did not seem to
ease and continued to cause pain when walking to the shops and around
the home. The pain during the night was reduced; however, on getting out
of the bed in the morning her knee was very stiff, although this stiffness
eased once she was out of the shower and having breakfast.
The pain was like a dull ache in nature and was always worse when
weight-bearing as opposed to sitting down. The pain was mainly concen –
trated around her right knee although the thigh also ached. To help it Mrs
V rubbed it and covered it with a blanket when at home to keep it warm.
Her daughter suggested that she took some paracetamol but Mrs V was
never keen on taking any tablets, especially for more than one day and $ Patient’s perspective

Osteoarthritis · facts
62declined. Her husband thought she should visit the doctor—Mrs V did
not like going to see doctors—‘It will get better’ she told everyone.
She found that the pain did not improve although she did have good and
bad spells. Over the next couple of weeks she stopped walking the dog
for fear of exacerbating the pain. Her husband started to do some of the
chores at home so that she could rest her knee. Mrs V was now worried
what was happening, her husband was now taking over her role at home
and had started to drive her everywhere. She was missing her friends from
work and was beginning to feel a little isolated and dependent on her
husband; she thought ‘This was not how things were meant to be in my
retirement’. The pain was unpleasant, and her husband and daughters
had noticed a change in her mood. She was snappy and did not seem to
look forward to seeing the grandchildren at the weekend. Worst of all, the
knee looked fine to her friends and they thought she might just be exag –
gerating the pain.
After a few weeks from the onset of the pain she visited the doctor and fol –
lowing an examination of her knee and listening to the history of the pain
onset he suggested that she may have osteoarthritis of the knee. He also
noted that she had some osteoarthritis of the fingers also. He suggested
that she tried some NSAIDs in the first instance to address the pain and
wanted to review her in 2 weeks.
The pain did improve a little and walking became a little easier but it
was still present. The doctor was not keen for Mrs V to continue with the
NSAIDs long term due to their unwanted side effects and suggested that
she tried paracetamol on a regular basis. He gave her some literature pro –
vided by the Arthritis and Rheumatism Council (ARC) and referred her
on to a physiotherapist.
The literature was very interesting and Mrs V showed it to her daugh –
ters. They used some of the websites suggested for further information.
Although Mrs V did not want to have osteoarthritis she was somewhat
relieved to hear from the physiotherapist that she would not end up
in a wheelchair and that she would be able to walk her dogs, albeit in
moderation.
The physiotherapist explained the importance of good muscle strength,
and talked about some ways of achieving this that she could do at home.
They also discussed how to manage her daily routines to ensure that she
achieved things that were important to her. She realized that over the past

chapter 6 · The management of osteoarthritis—an overview
63few years of relying on busses and cars she had gained some unwanted
and unhelpful weight, especially more recently in the past 2 to 3 months
when she missed walking the dog. She discussed with her daughters how
to lose weight and about glucosamine sulphate. Her mood lifted with all
the treatments she could do for herself.
Ten years later Mrs V feels the pain is well managed. She still feels in con –
trol at home, having learnt to pace herself. Tennis is not so easy but she
managed to get involved as the club secretary and has also taken up bowls
(which is a slower sport). She continues to keep check of her weight and
now that her husband has diabetes they share a healthy diet. Her grand –
children enjoyed taking nanny shopping for some sneakers (for dog walk –
ing) and heels are only worn at weddings. Her hand pain has now settled
although she does have some nodules on some of the fingers. Some rings
are now difficult to get on and off and decorating cakes is not quite as
easy, but the grandchildren now enjoy doing their own. Occasionally Mrs
V gets a slight ache in her left knee, but this time she is not panicking. She
has learnt that there are many things that she can do herself to ensure that
the osteoarthritis does not take over her life.

65Regular, moderate exercise offers a whole host of benefits to people with oste –
oarthritis, including stimulating the tissues of the joint and building strong
muscles around the joint, and through this can reduce stiffness, pain, and
swelling. Regular physical activity also has long-term effects on your well-
being. It helps promote overall health and fitness, which gives you more ener –
gy, helps you sleep better, controls your weight, assists in alleviating depres –
sion, and improves your self-esteem. Also, physical exercise has beneficial
effects for your cardiovascular health, and this is particularly important in
patients with OA, as recent research has shown that those affected with OA
have an increased risk of serious cardiovascular events such as heart attacks.
Exercise also affects your overall well-being by:
◆ improving your self-esteem
◆ relieving depression
◆ decreasing anxiety
◆ promoting general health
◆ increasing your cardiovascular fitness7
The role of exercise
% Key points
◆ Research has shown that participating in a regular exercise programme
is a great way to feel better and move more comfortably.
◆ The benefit you attain will be commensurate with the effort you put it.
◆ Optimally you should engage in a broad range of activities that suit
you and your lifestyle.

Osteoarthritis · facts
66◆ giving you more energy and reducing fatigue
◆ helping you sleep better
◆ helping you lose weight or keeping your weight down.
Improvements in mood and wellbeing have been reported by regular exer –
cisers in both clinical and non-clinical populations and with most types of
exercise. Baseline levels of anxiety are lower in individuals who exercise regu –
larly as compared with sedentary adults. Because depression is a concern for
individuals with osteoarthritis, physical activity is an important psychological
adjunct to treatment. Lastly, exercise can also help stave off other health prob –
lems such as osteoporosis, diabetes, and heart disease.
An exercise programme: general guidelines
What types of exercise are most suitable for someone with osteoarthritis?
The best type of exercise programme for you will depend on which joints are
affected and the severity of involvement. Y ou should seek professional advice
from an expert (such as a physiotherapist) who can devise a programme that
caters for your specific needs. This should include a variety of options that
you can follow depending on the location and severity of your osteoarthritis.
It should also take into consideration what type of activities appeal to you so
that you are motivated to do it regularly. There is a broad range of activities
that are considered appropriate exercise for people with osteoarthritis and the
best of these are:
◆ Range-of-motion (ROM) exercises (e.g. cycling, dance) : these will help main –
tain normal joint movement and relieve stiffness, and help maintain or
increase flexibility. Individuals with osteoarthritis often have a limited
range of motion, especially in their lower extremity joints such as the
knees or hips. Decreased range of motion associated with knee and hip
OA is associated with pain, loss of function, physical limitations, and an
increased risk of injury and falls. In addition, to receive adequate nutrition
the joint requires regular compression and decompression to stimulate
remodelling and repair. Ideally a daily exercise plan should include ROM
exercises and these should be specified by an exercise professional—not
just ‘a stretch every day’—because affected joints that are lax are easily
overstretched and more vulnerable to injury.
◆ W ater aerobics : aquatic aerobic training programmes that are offered in
therapeutic pools are one of the best forms of exercise. Aquatic exer –
cise has over the years been known as pool therapy, hydrotherapy, and

chapter 7 · The role of exercise
67sometimes in earlier literature even balneotherapy.1 The treatment has to
take part in water and involve exercises. Pools that are designed for per –
sons with arthritis are often kept at much warmer temperatures than rec –
reational pools and may have specialized access ramps to make entrance
to the pool easier. This type of exercise helps to maintain range of motion
of joints and also aerobic fitness. For someone with pain in the knees or
hips that is related to bearing weight on the joint, exercise on land can
often be painful. In contrast, exercising in water where your body weight is
partly supported can greatly enhance your ability to exercise without this
discomfort.
◆ Strengthening exercises (e.g. weight training) : these help keep or increase
muscle strength so the muscles are strong enough to support and pro –
tect joints affected by arthritis. The best type of strengthening programme
is one that takes into account personal preferences, the type of arthritis
involved, and the severity of the inflammation. Strength training can be
done with small free weights, exercise machines, isometrics, elastic bands,
and resistive water exercises. Correct positioning is critical because, if
done incorrectly, strengthening exercises can cause muscle tears or more
joint pain. In order to maximize the effectiveness of strengthening exercise
it is necessary to combine strengthening exercises with a more complete
exercise programme including ROM, stretching, functional balance, and
aerobic exercises (Figure 7.1).
◆ Aerobic or endurance exercises (e.g. bicycle riding, walking) : these improve car –
diovascular fitness, help control weight, and enhance general health and
well-being. Weight control can be important for people who have arthritis
because extra weight puts extra pressure on many joints. It is important
that this type of exercise not be high in impact (such as the heavy pounding
of road running) because the pressure on affected joints can have deleteri –
ous effects. Many health clubs, swimming pools, and community centres
offer exercise programmes for people with physical limitations that include
walking, cycling, aquatics, and aerobic dance. Participants in aerobic pro –
grammes have reported the following improvements: (1) increased aerobic
capacity, (2) decreased depression and anxiety, (3) increased physical activ –
ity, (4) decreased fatigue, (5) increased muscular strength and flexibility,
(6) decreased pain, (7) and increased functional status2 It was also found
that these benefits were achieved without an increase in pain or further
exacerbation of osteoarthritic symptoms. Interestingly enough, these find –
ings conflict with earlier beliefs that repetitive motion causes further injury.
We cannot stress enough the importance of keeping up your cardiovas –
cular fitness as recent data have shown that patients with OA have an

Osteoarthritis · facts
68Figure 7.1 Some of the exercises that are used for persons with knee OA include knee
extension, modified squat, and squat and side lift

chapter 7 · The role of exercise
69increased risk of heart attacks. Aerobic exercise has a big role in the pre –
vention of cardiovascular events.
◆ Recreational/lifestyle activities : any recreational, or lifestyle, activity of mod –
erate intensity, such as gardening or walking, is an important form of exer –
cise, and does not need to be undertaken in a single session. For example,
according to research, the benefits from three 10-minute walks or one
30-minute walk are similar. Current health guidelines recommend that
people of all ages strive to accumulate 30 minutes of moderate intensity
lifestyle activities throughout the day on most days of the week.
Examples of moderate-intensity lifestyle activities include walking, raking
leaves, gardening—even simply using the stairs. There are lots of ways to
make changes to how you do certain routine tasks that will add up to
important increases in your daily activity. Some examples include parking
at a far end of shopping centre parking lot, walking around during TV ad
breaks, and going up and down every supermarket aisle.
Table 7.1 Recommended physical activity for adults with osteoarthritis
Aerobic exercise programme components
Frequency: 3–5 days per week
Duration: 20–60 minutes per session (at least 150 minutes/week)
Intensity: Moderate (you are breathing harder than normal but still able to speak
in sentences) to vigorous (you are out of breath and can only speak one
word at a time)
Type: Low impact such as walking (see ‘How does a person with osteoarthritis
start an exercise programme?’ section for more information)
Muscle strengthening exercise programme components
Frequency: 2–3 days per week
Duration: 8–12 repetitions; all major muscle groups
Intensity: Moderate to vigorous (the exercise needs to feel ‘hard’ or ‘very hard’ while
you’re doing it)
Type: See ‘How does a person with osteoarthritis start an exercise programme?’
section for more information
Source : data from Physical Activity Guidelines Advisory Committee, Physical Activity Guidelines
Advisory Committee Report, 2008 , Washington, DC, US Department of Health and Human Services,
2008, available from <http://www.health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf>.

Osteoarthritis · facts
70For people with osteoarthritis, lifestyle activities, rather than traditional vigor –
ous types of exercise, may be especially appropriate for several reasons: first,
short bouts of exercise (as opposed to one continuous session) may reduce
pain and prevent injury; second, intermittent episodes of activity allow indi –
viduals with arthritis more flexibility in alternating physical activity with rest;
third, they provide a means by which a person who has been sedentary for a
while can begin and feel able to do an exercise programme (see Table 7.1).
How does a person with osteoarthritis start
an exercise programme?
Starting an exercise programme can seem like a daunting proposition. The
two important things to remember are: (1) start slowly, and (2) make it fun.
People with osteoarthritis should discuss exercise options with their doctors and
other healthcare providers. Many people with osteoarthritis begin with easy,
ROM exercises, aquatic exercise, or low-impact aerobics. People with osteoar –
thritis can participate in a variety of, but not all, sports and exercise programmes.
The doctor will know which, if any, sports are off limits. They may have sugges –
tions about what programmes are available locally, about how to get started or
may refer the patient to a physiotherapist or exercise therapist. The therapist will
design an appropriate home exercise programme and teach clients about pain-
relief methods, proper body mechanics (placement of the body for a given task,
such as lifting a heavy box), joint protection, and how to conserve energy.
Here are some step-by-step guidelines to follow:
◆ Apply heat to sore joints (optional)—many people with osteoarthritis start
their exercise programme this way.
◆ Stretch and warm up with ROM exercises.
◆ Start strengthening exercises slowly with small weights (a 1- or 2-kilograms
weight can make a big difference).
◆ Progress slowly.
◆ Use cold packs after exercising (optional)—many people with osteoarthri –
tis complete their exercise routine this way.
◆ Add aerobic exercises.
◆ Consider appropriate recreational exercise (after doing ROM, strengthen –
ing, and aerobic exercises). Fewer injuries to joints affected by osteoarthritis

chapter 7 · The role of exercise
71occur during recreational exercise if it is preceded by range of motion,
strengthening and aerobic exercises.
◆ IMPORTANT NOTE: ease off if joints become painful.
Important exercise guidelines for a person
with osteoarthritis
The three important concepts that you need to remember at all times are:
1. Begin slowly and progress gradually : the hallmark of a safe exercise pro –
gramme is gradual progression in exercise intensity, complexity of move –
ments, and duration. Often people with osteoarthritis have lower levels
of fitness due to pain, stiffness, or biomechanical abnormalities that may
have led to periods of immobility. Thus, beginning with a few minutes of
activity, and alternating activity with rest, should be one of the initial goals.
2. Avoid rapid or repetitive movements of affected joints : special emphasis should
be placed on joint protection strategies and avoidance of activities that
require rapid repetitions of a movement or those that are highly percus –
sive in nature. Because faster walking speeds increase joint stress, walking
speed should be appropriate. Special attention must be paid to joints that
are unstable. Control of shock absorption through shoe selection or use of
orthotics (inserts) may be necessary.
3. Ensure the physical activity is appropriate to your needs : affected joints may be
unstable and restricted in range of motion by pain, stiffness, swelling, bone
changes, or fibrosis. These joints are at higher risk for injury and care must
be taken to ensure that appropriate joint protection measures are in place.
Joint protection refers to not placing undue stress on the joints affected
by your arthritis. Activities that involve high impact, such as running, for
knees and hips may exacerbate osteoarthritis affecting these areas. In this
instance try low-impact exercise such as water aerobics or cycling.
What pain relief can you use during exercise?
Temporary pain relief can make it easier for people who have arthritis to exer –
cise. Y our doctor or physiotherapist can suggest a method that is best for you.
The following methods have worked for many people:
◆ Moist heat supplied by warm towels, hot packs, a bath, or a shower can be
used at home for 15–20 minutes three times a day to relieve symptoms.

Osteoarthritis · facts
72◆ Cold supplied by a bag of ice or frozen vegetables wrapped in a towel helps
to stop pain and reduce swelling when used for 10–15 minutes at a time.
◆ Hydrotherapy (water therapy) can decrease pain and stiffness. Exercising
in a large pool may be easier because water takes some weight off painful
joints.
◆ Mobilization therapies include traction (gentle, steady pulling), massage,
and manipulation (using the hands to restore normal movement to stiff
joints).
◆ Relaxation therapy also helps reduce pain. Patients can learn to release the
tension in their muscles to relieve pain.
◆ Acupuncture is a traditional Chinese method of pain relief in which a med –
ically qualified acupuncturist places needles in certain sites. Researchers
believe that the needles stimulate deep sensory nerves that tell the brain to
release natural painkillers (endorphins).
How often should people with arthritis exercise?
◆ ROM exercises can be done daily and should be done at least every other
day.
◆ Strengthening exercises should be done every other day unless you have
severe pain or swelling in your joints.
◆ Endurance exercises should be done for 20–30 minutes three times a week
unless you have severe pain or swelling in your joints.
How much exercise is too much?
Most experts agree that if exercise causes pain that lasts for more than 1 hour,
then it is too strenuous. People with arthritis should work with their physi –
otherapist or doctor to adjust their exercise programme if they notice any:
◆ unusual or persistent fatigue
◆ increased weakness
◆ decreased range of motion
◆ continuing pain (pain that lasts more than 2 hours after exercising).

chapter 7 · The role of exercise
73What could happen if I don’t exercise?
If your joints hurt, you may not feel like exercising. However, if you don’t exer –
cise, your joints can become even more stiff and painful. Exercise is beneficial
because it keeps your muscles, bones, and joints healthy.
Because you have osteoarthritis, it is important to keep your muscles as strong
as possible. The stronger the muscles and tissue are around your joints, the
better they will be able to support and protect those joints—even those that
are weak and damaged from osteoarthritis. If you don’t exercise, your muscles
become smaller and weaker.
Many people with osteoarthritis keep painful joints in a bent position because
at first it’s more comfortable. But if your joints stay in one position for too long
(without movement), you may lose your ability to straighten them. Exercise
helps keep your joints as flexible as possible, allowing you to continue to do
your daily tasks as independently as possible.
Exercise can change your mood. If you’re in pain, you may feel depressed. If
you feel depressed, you may not feel like moving or exercising. But without
exercise, you may feel more pain and depression. Research has shown that
participating in a regular exercise programme is a great way to feel better and
move more comfortably.
Keeping on with exercise
It is important to do an ongoing exercise programme in order to get the ben –
efits of exercise for your OA. Of course, we all know that we can have good
intentions, but sometimes it is difficult to exercise regularly and to keep going
over the long term. There are some things that may help you:
◆ Set yourself some short-term goals with regards to your exercise that are
easily achievable.
◆ Reward yourself for achieving your exercise goals but don’t be hard on
yourself if you don’t.
◆ Keep a diary or log book to record when and how much exercise you do.
◆ Use a pedometer to count how many steps you are taking each day.
◆ Enlist the support of family and friends—get them to join in or to keep
you on track.
◆ Join a group exercise programme.

Osteoarthritis · facts
74◆ Vary the types of exercise that you do so that you don’t get bored.
◆ Try different activities—join a dance class or walking group.
◆ Make social plans with family and friends that are active rather than inac –
tive (such as meeting for a walk in the park rather than catching up at a
café).
◆ Make small changes to your daily routine.
◆ Monitor over the long term via periodic reassessment by a health
professional.
Two particular forms of exercise that have proven beneficial to people with
osteoarthritis are yoga and t’ai chi. These can involve ROM and strengthening
exercises and can become a type of lifestyle activity, which can be done any –
where for any period of time that is appropriate.
Yoga
Y oga is a set of theories and practices with origins in ancient India. Literally,
the word yoga comes from a Sanskrit word meaning ‘to yoke’ or ‘to unite’.
It focuses on unifying the mind, body, and spirit, and fostering greater self-
awareness and connection between the individual and his/her surroundings.
As interest in yoga has increased in Western countries over the last few dec –
ades, yoga postures are increasingly practised solely for physical health bene –
fits. This physical practice of yoga, often called hatha yoga, sometimes overlaps
or includes references to the other aspects of yoga, such as meditative practic –
es. A popular misconception is that yoga focuses merely on increasing flexibil –
ity. The practice of hatha yoga also emphasizes postural alignment, strength,
endurance, and balance.
Today’s yoga participants are young and old, flexible and inflexible, shapely
and out of shape—everyday people who want to treat their bodies and minds
well. Numerous scientific trials on yoga have been published in major medi –
cal journals. These studies have shown that yoga is a safe and effective way to
increase physical activity and also has important psychological benefits due
to its meditative nature. As with other forms of exercise, yoga can increase
muscle strength, improve flexibility, enhance respiratory endurance, and pro –
mote balance. Y oga is also associated with increased energy and fewer bodily
aches and pains. Finally, yoga is associated with increased mental energy as
well as positive feelings (such as alertness and enthusiasm), and fewer negative
feelings (reduced excitability, anxiety, aggressiveness) and somatic complaints.

chapter 7 · The role of exercise
75In summary, yoga is associated with a wide range of physical and psychologi –
cal benefits that may be especially helpful for persons living with osteoarthri –
tis. Y oga poses can help strengthen your joints and the muscles around them
which is crucial in preventing and dealing with osteoarthritis. It also increases
the ROM in joints thus reducing the risk of stiffness.
A core concept of yoga is that it is not competitive or goal-oriented; it is about
tuning into your own body and its limitations and doing what it needs on a par –
ticular day. Ideally your yoga teacher (assuming you are in a class) will empha –
size the importance of approaching your yoga practice with this awareness.
While there are some yoga poses that do require a great deal of flexibility,
strength, and balance, those poses should only be attempted by very expe –
rienced yogis and are not for beginners or persons with physical limitations.
Again, a good yoga teacher will provide alternatives and modifications to all
activities so that students can work within their levels of comfort.
The general rule for people with osteoarthritis is that if it hurts, stop. The old
adage of ‘no pain, no gain’ does not apply to yoga, particularly if you have
physical limitations. When doing backbends, people with back pain should
keep them relatively small. For those with arthritis of the hip, be cautious
when doing ‘hip openers’ or poses with extreme external rotation of the hips.
Generally, you will notice pain if you are going too far with the pose, but some –
times the effects are not felt until the next day. It is important to be gentle with
your practice, especially at first. If you do not experience any pain after a few
days, you can decide to gradually increase the intensity of the poses. As with
any condition, it is important to be cautious and pay attention to your body
and consult your doctor before commencing the programme. Also, be sure
to consult your doctor and instructor if you experience any pain or difficulty
resulting from yoga practice.
T’ai chi
T’ai chi is an ancient Chinese practice designed to exercise the body, mind,
and spirit. Moving through t’ai chi positions gently works muscles, focuses
concentration, and, according to Chinese philosophy, improves the flow of
‘qi’, the vital life energy that sustains health and calms the mind (qi is pro –
nounced ‘chee’ and is often spelled ‘chi’). Chinese medicine is based on the
belief that disease is due to blocks or imbalances in the flow of qi.
Chinese medicine incorporates the use of acupuncture, herbs and t’ai chi in
the belief they can help balance the flow of qi, and, in doing so, cure illness
and maintain health.

Osteoarthritis · facts
76In the thirteenth century, Taoist priest Chang San Fang observed a crane
fighting with a snake and compared their movements to yin and yang. Some
t’ai chi movements are said to mimic those of the animals. In China, where
t’ai chi has been practised for some 600 years, t’ai chi isn’t just a feel-good
workout but a therapy, preventive measure, and remedy for almost every ail –
ment, including osteoarthritis. Given its low impact and evidence that it tends
to increase muscle strength and balance and give general pain relief, t’ai chi is
a worthwhile option for many people with osteoarthritis.
Along with other Chinese imports, such as acupuncture and herbs, t’ai chi is
becoming popular in the West. It appeals to people of all ages because it’s not
intimidating. Seniors particularly like t’ai chi because the slow, synchronized
movements are easy to learn and to perform.
T’ai chi movements are based on shifting body weight through a series of light,
controlled movements that flow rhythmically together into one long, graceful
gesture. The sequences have poetic names, such as ‘waving hand in the cloud’
or ‘pushing the mountain’, and can be quite beautiful to an observer. T’ai chi
takes the joints gently through their range of motion, while the emphasis on
breathing and inner stillness relieves stress and anxiety.
Classes are inexpensive, and it can be practised almost anywhere at any time,
with no special equipment or clothing.
T’ai chi classes are usually small, with fewer than 20 people of diverse ages.
It’s common to see people in their 80s alongside students in their 20s and
every age in between.
There are five distinct styles of t’ai chi and many variations within each style. The
most gentle and, therefore, most suitable styles for people with osteoarthritis, are
the Yang, Sun, Wu, and Hao styles. Beginners should avoid the Chen style, a more
brisk and active style that is not recommended for most people with arthritis.
Y ou may encounter a t’ai chi class that teaches a variation on a style or one
that combines several styles. The ‘right’ version for you is one that you can do
easily, without making hard or forceful movements and without stressing your
joints or muscles.
T’ai chi classes usually last about 1 hour, and may be held once or twice a
week. They begin with a gentle warm-up and breathing exercises or a medita –
tion to quiet the mind.
The teacher demonstrates individual poses and then leads the class through
the sequences, step by step, gradually linking the movements together in longer

chapter 7 · The role of exercise
77sequences. The sequences can be done slowly, or with more speed and energy.
But movements are always soft and graceful, with careful attention to breath –
ing and posture. The movements are inspired by the martial arts, but require
no jumping or jerking of the body.
Classes end with cooling-down exercises and, sometimes, a short meditation.
At the end of class, you should feel relaxed. If you have pain that lasts more
than a few hours after class, talk to the instructor about how to change the
movements to work within your limits.
T’ai chi has been shown to decrease pain and joint stiffness, and improve
physical function, and balance in persons with osteoarthritis.3 The ‘Sun-style’
t’ai chi reported on in this study was designed specifically for patients with
osteoarthritis. It involves slow, continuous, and gentle motions with a higher
stance than other t’ai chi styles.
Some studies have reported that t’ai chi can reduce the risk of falls, and this is
important in patients with OA, as they are at an increased risk of falls, leading
to an increased risk of fractures.
Sore muscles, sprains, and electrical sensations have been reported rarely with
t’ai chi. T’ai chi should not be used as a substitute for more proven therapies
for potentially severe medical conditions. Consult a qualified healthcare pro –
vider if you experience dizziness, shortness of breath, chest pain, headache, or
severe pain related to t’ai chi.
References
1. Bartels EM. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane
Database of Systematic Reviews 2006; 4:CD005523.
2. Regnaux J-P, Trinquart L, Boutron I, Nguyen C, Brosseau L, Ravaud P. High-
intensity versus low-intensity physical activity or exercise in patients with hip or knee
osteoarthritis. Cochrane Database of Systematic Reviews 2012; 11:CD010203.
3. Song R, Lee EO, Lam P, Bae SC, Song R, Lee EO, et al. Effects of tai chi exercise on
pain, balance, muscle strength, and perceived difficulties in physical functioning in older
women with osteoarthritis: a randomized clinical trial. Journal of Rheumatology 2003;
30(9):2039–2044.

79For many years researchers have been exploring the link between diet and
osteoarthritis. We continue to hear claims that special diets, foods, and supple –
ments may help to cure or alleviate symptoms of osteoarthritis, but most claims
are unproven. Many experts speculate that claims of nutritional remedies and
cures with food or dietary supplements are related to the ‘placebo effect’, which
is when the patient perceives that their symptoms and well-being have improved
after new therapy, regardless of evidence for actual physical improvement.
Because there is little scientific evidence confirming the benefits of specialized
diets for patients with osteoarthritis, health professionals are cautious about
recommending these types of dietary manipulations to their patients.
However, there are others with limited or no medical background who will
provide advice about the benefits of diets for osteoarthritis. The advice given is
often questionable, expensive, and can be dangerous.
In short, there is a lot of confusing advice in magazines and books on diet and
many food supplements that reportedly help with osteoarthritis. Some people
end up taking expensive food supplements or eat elaborate diets that do not help, 8
The role of diet
and weight loss
% Key points
If you have osteoarthritis the most important guidelines on diet are that
you:
◆ attain a balanced diet
◆ include foods that contain essential fatty acids
◆ and keep your weight at a healthy level.

Osteoarthritis · facts
80or may even be harmful. Often the best results can be achieved by simpler, cheap –
er methods. If you have osteoarthritis the most important guidelines on diet are
that you attain a balanced diet, include foods that contain essential fatty acids
(one aspect of the diet that can have a beneficial effect), and keep your weight at
a healthy level. In addition, many people with OA are overweight or obese and
caloric restriction is a vital ingredient of any weight-loss programme. The infor –
mation you need to follow these guidelines is included in the following sections, as
well as some background facts that dispel some commonly held misconceptions.
If you are looking for individualized nutrition advice, you are best to contact a
dietitian for a nutritional assessment.
A balanced diet
The right diet can certainly help some people with OA. Until we have access
to more conclusive data regarding the benefits of dietary manipulation for
OA, patients are encouraged to follow a healthy, balanced diet that fosters a
healthy weight. The main messages are as follows (see Figure 8.1):
◆ Achieve a healthy weight, be physically active, and choose amounts of
nutritious food and drink to meet your energy needs.
◆ Enjoy a wide variety of nutritious foods from the five food groups:
❍ Plenty of vegetables of different types and colours.
❍ Legumes/beans.
❍ Fruit.
1/3 fruit an d
vegetable s
(not potatoes)
1/8 pr otein
(such as fish, meat ,
eggs, pulses, soya
products )Occasion al fatty and
suga ry foods (sweet s, ice cr eam,
cakes, butter , cream)1/6 dair y products
(such as milk , chee se,
yogu rt, but no t
butt er or cream)1/3 star chy fo ods
(such as br ead, ce reals,
potatoes, pasta)
Figure 8.1 Eat a diet which has the right balance of different types of food

chapter 8 · The role of diet and weight loss
81❍ Grains (cereal) foods, mostly wholegrain and/or high cereal fibre vari –
eties, such as breads, cereals, rice, pasta, noodles, polenta, couscous,
oats, quinoa, and barley.
❍ Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/
beans.
❍ Milk, yogurt, cheese, and/or their alternatives, mostly reduced fat.
◆ Drink plenty of water.
◆ Limit intake of foods containing saturated fat such as many biscuits, cakes,
pastries, pies, processed meats, commercially made burgers, pizza, fried
foods, potato chips, and other savoury snacks.
◆ Limit intake of foods and drinks containing added salt.
◆ Limit intake of foods and drinks containing added sugars such as con –
fectionary, sugar-sweetened soft drinks and cordials, fruit drinks, vitamin
waters, energy and sports drinks.
◆ If you do choose to drink alcohol, limit intake.
◆ Ensure you are getting adequate omega-3 fatty acids, and vitamins D and
K in your diet.
NOTE: avoid elimination diets and fad nutritional practices and be cautious
of claims of miracle cures.
Weight control
The most important single link between your diet and OA is certainly your
weight. Being overweight puts an extra burden on the weight-bearing joints
(back, hips, knees, ankles, and feet) when they are already damaged or under
strain. Because of the way joints work, the effect of the weight can be four or
five times greater in important parts of the joint. For example, being only 4.5
kilograms overweight increases the force on the knee by 13–27 kilograms with
each step. If you are overweight and have OA in any of your weight-bearing
joints, losing weight will help you more than any food supplements. The com –
bination of weight loss and exercise has been shown in clinical trials to provide
large improvements in knee OA symptoms (pain and mobility).
Being overweight is a clear risk factor for developing OA, and the increas –
ing and worsening of symptoms of existing disease. Overweight women have
nearly four times the risk of knee OA; for overweight men the risk is five times

Osteoarthritis · facts
82greater. Obese people with knee OA are also more likely to progress rapidly to
need joint replacement surgery.
How do I know if I am overweight?
The use of the body mass index (BMI) as an indicator of healthy and
unhealthy weights is based on extensive research linking the index with asso –
ciated health risks. Y our BMI is calculated by dividing your weight in kilograms
by the square of your height in metres . According to the new guidelines from
the US National Institutes of Health, someone with a BMI of 25–29.9 is
overweight, while obesity is a BMI of greater than 30. (A BMI of 30 is about
15 kilograms overweight.) Y ou should aim for a BMI between 18.5 and 25
if you are between 18 and 65. If you are over 65 years of age, your healthy
BMI is between 22 and 27. It is important to be aware that the BMI does
not distinguish between weight attributed to muscle and weight attributed to
fat. It is therefore not appropriate for use for elite athletes, body builders, or
pregnant women.
BMI is a simple and easy way to determine your weight status; however,
another important measure is waist circumference. A waist measurement
of greater than 94 cm for men or 80 cm for women is an indicator of inter –
nal fat deposits, which can coat the heart, kidneys, liver, and pancreas, and
increase the risk of chronic diseases such as diabetes, heart disease, or some
cancers.
What is the best way to lose weight?
Slimming has become big business. There are many slimming treatments and
so-called miracle diets, and this can be confusing. Unfortunately there is no
miracle cure. Crash and fad diets are usually unbalanced and are not recom –
mended. Most people find they put weight back on when they return to nor –
mal eating. The only way to lose weight permanently is to change what you eat in a
way that is sustainable in the long term.
To work normally, your body needs food to supply energy, protein, and a vari –
ety of vitamins and minerals. If your diet contains more energy than you burn
up, your body will convert the extra energy to fat and you will put on weight.
On the other hand, if your food contains less energy than you are using, you
will lose weight. If your OA, or other health problems are limiting your abil –
ity to participate in as much physical activity or exercise as previous stages in
your life, your body needs less energy and therefore you need to be careful of
how much energy you are consuming.

chapter 8 · The role of diet and weight loss
83The energy in food is measured in kilocalories (kcal)—sometimes just called
calories—or kilojoules (kJs). The energy in food comes from all food and drink
items. It is important to know which foods provide a lot of calories/kilojoules
when you are intending to lose weight. It is also important to be aware of the
portion sizes of food you consume.
Another important thing to remember when attempting to eat fewer calories/
kilojoules is that is important not to eat less vitamins and minerals at the same
time. This is why it is important to eat foods that have a lot of vitamins and
minerals per calorie, such as fruit and vegetables. Fruit and vegetables also
provide you with fibre, which assists in managing hunger levels and keeps your
bowels regular.
Cut down on the fat you eat
Fat has twice as many calories as the same weight of carbohydrate (sugars and
starches) or protein.
Most people eat far more fat than they need for health. Fat contains about
9 kcal/g (37 kJ), whereas protein and carbohydrates contain about 4 kcal/g
(17 kJ). Eating about 30 g (1 oz) less fat each day saves 270 calories (1128 kJ)!
This is an example of how cutting calories does not require massive sacri –
fices. Making minor changes in the foods you eat can do the trick.
The fats in food are of three kinds: saturated, monosaturated, and polyunsatu –
rated. Saturated fats by definition are solid at room temperature and are found
mostly in animal fats, such as the fat on meat, full cream dairy products (such
as milk, yogurt, cheese, cream, and butter), biscuits, pastry, pies, processed
meats, commercially produced burgers or pizzas, fried foods potato chips, and
crisps. Some vegetable fats are also high in saturated fat including coconut
oil/milk/cream and palm oil. Saturated fats are the most important kind of fat
to reduce: they have a negative impact on heart health and they may actually
aggravate OA. Softer fats and oils have more monosaturated and polyunsatu –
rated fats but just as many calories, so limiting them is still important to lose
weight.
To eat less fat, follow these rules:
◆ Look out for and avoid ‘invisible’ fats in foods such as biscuits, cakes,
chocolate, pastry, and savoury snacks—check the labels.
◆ Trim fat off any meat you eat.
◆ Always choose lean cuts of meat.

Osteoarthritis · facts
84◆ Choose fish and poultry more often.
◆ Use low-fat milk (skimmed or semi-skimmed).
◆ Use low-fat spreads.
◆ Grill food instead of frying foods.
◆ Fill up on cereals, fruit, and vegetables.
Cut down on sugar
Sugar contains only calories and has no other food value (so-called empty
calories) so it can be cut down without any loss of nourishment. Eating about
30 g (1 oz) less sugar each day saves 112 calories! Try not to add sugar to
drinks and cereals. Although artificial sweeteners contain very few calories,
it is better to get used to food being less sweet by not adding them to drinks.
Dried fruit like raisins can be used to sweeten cereals and puddings; unlike
sugar and artificial sweeteners, they also provide vitamins and minerals.
Eat more fruit and vegetables
The World Health Organization recommends that we should have at least five
portions of fruit and vegetables every day. This is to make sure that the body
receives the important antioxidants and vitamins which it needs to protect it
during the stress of disease. Eating plenty of fruit and vegetables, especially
the brightly coloured varieties like carrots, tomatoes, beetroot, and broccoli,
also provides you with more fibre. Remember, you also get fibre from who –
legrain versions of bread, cereals, pasta, and rice. These foods are more filling
so they will also help if you are trying to lose weight!
Take regular exercise
Exercise is very important. Not only does it involve you using up calories
which would otherwise end up as fat, but it increases your strength and sup –
pleness. Exercise is good for your general health, especially the heart and cir –
culation. Of course, OA can make exercise difficult and painful, and the wrong
kind of exercise can make it worse. But exercise does not have to mean run –
ning a marathon! A daily walk for half an hour with the dog or a walk to the
local shops or park is exercise and it will help.
Many people find particular types of exercise suit them best. Some prefer
swimming because being in water takes the weight off the joints; others prefer

chapter 8 · The role of diet and weight loss
85keep-fit classes, yoga, or cycling. The most important thing is that you enjoy it
and do it regularly (see Chapter 7).
What about weight-loss medications?
Clinical guidelines suggest that all patients try lifestyle-based (diet and exer –
cise) approaches for weight loss for at least 6 months before embarking on
drug therapy.
Weight-loss drugs for long-term use may be tried as part of a comprehensive
weight-loss programme that includes dietary therapy and physical activity in
carefully selected patients (BMI greater than 30 without additional risk fac –
tors, BMI greater than 27 with two or more risk factors) who have been unable
to lose weight or maintain weight loss with conventional non-drug therapies.
In general, if a patient does not lose 2 kilograms in the first 4 weeks of treat –
ment, the patient can be considered a non-responder to pharmacotherapy.
Drug therapy may also be used during the weight maintenance phase of treat –
ment. Surgical management is yet another option that typically is reserved for
the morbidly obese.
Essential fatty acids
One of the most exciting recent discoveries is that certain kinds of oil in the
diet help some people with OA. These oils contain essential fatty acids (EFAs).
Essential means that the body cannot make them for itself and must get them
from food. The body uses these EFAs to make chemicals called prostaglan –
dins and leukotrienes, the right balance of which has been shown to decrease
cartilage loss, decrease the activity of enzymes that break down cartilage, and
decrease the expression of mediators of inflammation. All of these factors may
explain the beneficial effects of omega-3 in OA.
There are two groups of EFAs: omega-3, found mostly in fish oil, and omega-
6, found mostly in plant seed oils. The typical Western diet is rich in omega-6
but does not contain enough omega-3.
Omega-3 EFAs are found naturally in oily fish, especially mackerel, sardines,
pilchards, and salmon, so it is a good idea to eat oily fish (for some the smell
may be troublesome) three or four times a week. They can also be found in
flaxseeds and flaxseed oil, walnuts, and canola oil. The main omega-3 EFAs
are called EPA and DHA, and most chemists and health food shops sell fish-
oil capsules which contain high concentrations of these. Y ou only need 180 mg
of EPA and 120 mg of DHA daily. Fish liver oil (cod or halibut) also contains
these EFAs as well as vitamin D, which helps the body to absorb calcium.

Osteoarthritis · facts
86But fish liver oils also contain a lot of vitamin A. This is dangerous in large
amounts, and in particular should not be taken by pregnant women, or
women who might become pregnant, because vitamin A can harm the unborn
baby. Women in these groups should not take fish liver oils or vitamin A sup –
plements at all. In most of the studies using fish oils, benefits are not usually
observed until at least 12 weeks of continuous use and appear to increase with
extended treatment time.
The main omega-6 EFA is called GLA. The best-known source is evening
primrose oil, but several other plant seed oils also contain it (safflower, sunflow –
er, and corn oil). Again these are available from most chemists and health food
shops, but as we have already suggested, your diet more than likely contains
enough omega-6 and you will only need to supplement omega-3 (Figure 8.2).
Are there side effects of EFAs?
In theory, EFAs can cause a problem by generating chemicals that cause
free radicals in the body, which could lead to heart and circulation disease.
Antioxidants are a group of vitamins and minerals that protect the body from
this. They are found mostly in fresh fruit and vegetables, especially the brightly
coloured varieties like carrots, tomatoes, beetroot, and broccoli. Most chem –
ists and health food shops stock antioxidant vitamin and mineral supplements.
It is also important to note that fish-oil supplements may interfere with
blood clotting and increase the risk for stroke especially when consumed Figure 8.2 Oily fish and some plant seed oils are sources of omega-3 polyunsaturated
fatty acids

chapter 8 · The role of diet and weight loss
87in conjunction with aspirin or other non-steroidal anti-inflammatory drugs
(NSAIDs).
Taking fish oils has also been linked to changes in bowel habits such as diar –
rhoea and may cause an upset stomach.
Other micronutrients
It is also important to ensure your diet has sufficient vitamin D and K.
Vitamin D is responsible for normal bone metabolism and potentially has
effects on cartilage metabolism. In some studies an intake less than 258 inter –
national units (IU)/day has been associated with an increased risk of progres –
sion, blood levels less than 30 nanograms/mL have been associated with an
increased risk of progression, osteophyte growth, and cartilage loss, and asso –
ciated with pain and decreased physical function. Furthermore, improving
blood levels of vitamin D improves physical function.
Recommended daily vitamin D requirements differ by age such that adults
aged 19–50 years are recommended to get 200 IU/day, adults 51–70 years
400 IU/day, and adults 71 years and older 600 IU/day.
Vitamin D is synthesized in the skin under the action of sunlight. Y ou can also
get it in certain foods: in particular milk is often fortified with vitamin D.
Some common causes of vitamin D deficiency include the following:
◆ Dark skin.
◆ Ageing.
◆ Wearing too much sunscreen, covering all exposed skin (some religions
recommend particular dress-codes like this), and not getting outside (such
as institutionalized persons in nursing homes).
◆ Obesity (vitamin D is fat-soluble: the more fat you have, the more vitamin
D you need).
Vitamin K is responsible for normal bone metabolism and potentially has
effects on cartilage metabolism. In some studies low blood levels of vitamin
K have been associated with an increased prevalence of knee and hand osteo –
arthritis. The recommended vitamin K requirements are 120 micrograms/day
for males and 90 micrograms/day for females. Some dietary sources that are
rich in vitamin K include soybeans, spinach, blueberries, and kale.

Osteoarthritis · facts
88Common misconceptions about diet and arthritis
A: Calcium is an important basic nutrient and not enough of it in the diet
contributes to osteoporosis (brittle bones). Women after the menopause
are particularly liable to osteoporosis. People with OA are statistically
at lower risk of developing osteoporosis. If you are at risk, the rich –
est source of calcium in most people’s diet is milk and dairy products
(foods made from milk: cheese, yoghurt, etc., but not butter). If you
have about 600 mL of milk per day or use other dairy products regu –
larly, you should be getting enough calcium. Remember that skimmed
milk contains more calcium than full-fat milk. A daily intake of calcium
of 1000 or 1500 mg if you are over 60 is recommended. The following
list can guide you on how much calcium is contained in some of the
common dietary foods.
Calcium content of common foods (figures provided are estimates
only):
◆ 0.2 litre (1/3 pint) whole milk: 220 mg
◆ 0.2 litre (1/3 pint) semi-skimmed milk: 230 mg
◆ 30 g (1 oz) hard cheese: 190 mg
◆ 150 g (5 oz) carton low-fat yoghurt: 225 mg
◆ 60 g (2 oz) sardines (including bones): 310 mg
◆ 3 large slices brown or white bread: 100 mg
◆ 3 large slices wholemeal bread: 55 mg
◆ 115 g (4 oz) cottage cheese: 80 mg
◆ 115 g (4 oz) baked beans: 60 mg
◆ 115 g (4 oz) boiled cabbage: 40 mg
If, for any reason, you do not take many dairy products, soya milk is
now available in most supermarkets and can be used in exactly the
same way as cows’ milk. Some soya milk is fortified with calcium, and Q: Should I take extra calcium if I have arthritis?# Questions and answers

chapter 8 · The role of diet and weight loss
89these are the better ones to have. If you are not taking dairy products
or a good quantity of soya milk, you may need a calcium supplement.
Discuss this with a dietitian or your doctor.
Q: Should I take iron tablets if I have arthritis?
A: Iron is important to prevent anaemia. Many people with OA are anae –
mic, but this will not always be helped by iron tablets. The anaemia
can be due to different causes. NSAIDs such as aspirin, ibuprofen, and
diclofenac help pain related to OA but may cause stomach ulcers and
bleeding in some people, leading to anaemia.
If you are anaemic your doctor will advise you if you need more iron.
The best source of iron in food is red meat. However, as many people
are now cutting down on red meat for various reasons, it is important
to have iron from other sources. Iron from fish is easily absorbed by
your body and oily fish are a very good source. For example, sardines
contain as much iron as beef! Iron is better absorbed if there is also
vitamin C in the meal so have a good portion of vegetables or salad or
fresh fruit with your meal. On the other hand, tea reduces the amount
of iron that your body can absorb so it is a good idea not to drink tea
with your meal. If you are vegetarian, remember that dairy products
like milk and cheese are a very poor source of iron, but pulses like
haricot beans and lentils and dark leafy vegetables (such as spinach and
watercress) are quite a good source. They should be included daily in
a vegetarian diet.
Q: Is it true that certain foods can make arthritis worse?
A: The best evidence we have that food can influence arthritis is from peo –
ple with gout. Gout is a particular type of arthritis where the body is not
able to properly absorb those foods that contain purines. This results in
too much uric acid, which can crystallize in the joints. Drugs have large –
ly replaced diet as a treatment for gout, but, if you have this condition,
you can avoid the main sources of purines in the diet—do not eat liver,
heart, kidney, meat extract, anchovies, crab, fish roe, herring, mackerel,
sardines, shrimps, and whitebait. Alcohol particularly affects uric acid
and people with gout should drink no alcohol at all or very little.
There has been some recent research about the effect of leaving certain
foods out of the diet in other forms of arthritis. Fasting by eliminating
certain foods from the diet is a very high-risk, short-term treatment and
is currently not an accepted modality for the treatment of OA.

91Complementary therapies for osteoarthritis have become more popular and
more widely available to the general public. According to recent surveys, in
many Western countries nearly half of all persons with OA are trying some
kind of unconventional therapy. This trend to complementary medicine sug –
gests that patients are increasingly dissatisfied with conventional medicine
and/or concerned about the side effects of prescribed medications.
In general, conventional medical treatments are safe and effective, but more
often than not drugs and surgery cannot fully control the symptoms of OA.
Thus it is not surprising that one of the most common complaints taken to
complementary practitioners is the persistent pain and limited function that
occurs with OA, despite these more conventional treatments. With no known
cure, it is often expected that this persistent discomfort or limited function has
to be endured. It may be as a consequence of this that many persons affected
with OA then seek out complementary therapies.
What are complementary therapies?
There are a wide variety of complementary therapies that range from ancient
systems of medicine such as homoeopathy and herbalism, to treatments such 9
Complementary
or alternative therapy
% Key points
◆ Complementary therapies can play an important role in encouraging
positive changes in lifestyle and outlook, such as increased self-reliance,
a positive attitude, relaxation practices, and appropriate exercises.
◆ Lifestyle changes like these may help to improve the pain and other
symptoms stemming from osteoarthritis.

Osteoarthritis · facts
92as massage and aromatherapy. A therapy is considered complementary or
alternative if it’s not traditionally being used in conventional medicine—but
this is changing.
Until well into the twentieth century, many of the therapies we now call com –
plementary were mainstream medicine. Doctors prescribed herbs and other
plant-based medicines, and performed massage and manipulations. Mental
attitudes, such as faith and the will to live, were considered an important part
of healing, and prevention was a major form of healthcare. Many of these
therapies are still considered mainstream medicine in other cultures.
Meanwhile, advances in medical science led to a more technical, intervention-
based healthcare that we commonly refer to as Western or conventional medi –
cine. The results of this type of care have been spectacular. Vaccines protect us
from a range of deadly diseases, antibiotics are truly life-saving, and surgery
can perform wonders. Our lifespan has been extended from an average age
of 48 at the beginning of the twentieth century to 76 as we entered the new
millennium. With these advances in medical technology, most medical schools
stopped teaching the older, more time-consuming treatments. In addition,
medical practices developed concern for their own fiscal responsibilities
and constrained the length of visits and thus patient–doctor interaction and
encouraged procedures that generate more income. In this less than patient-
friendly environment it is not surprising that people affected by chronic dis –
eases seek help elsewhere.
Often people want to turn back the clock by returning to complementary
medicine. Part of it is the frustration with today’s impersonal healthcare sys –
tem but equally important is the disappointment that, despite a wealth of
medical research, cures have still not been discovered for chronic illnesses
such as OA. Although Western medicine excels at treating acute ills such as
infections, emergencies, and accidents, there are still relatively few treatments
for illnesses that drag out over years or even decades. We are living longer with
chronic diseases that are more complex to treat. They usually have more than
one cause, and no simple solutions.
Alternative therapies may offer tools and remedies that, along with main –
stream medicine, can influence your overall health. For example, there is evi –
dence that emotions and mental attitudes can have a major impact in the
long-term management of chronic illness. An interest in alternative therapies
shows that you want to take a more active role in your healthcare, and the
sense of control that you gain by becoming involved in managing your OA can
contribute to your overall well-being.

chapter 9 · Complementary or alternative therapy
93Choosing a complementary therapy
There are two important principles to follow when considering using a com –
plementary therapy: be properly informed and use your common sense.
There’s no free lunch, and there are no miracle cures for OA.
Unconventional therapies are remedies that, along with mainstream medicine,
may improve your symptoms—and may not. Weigh the risks and benefits as
well as the costs in time and money, and know when to quit a therapy that isn’t
working for you. Ask your doctor to be your partner as you explore adding
unconventional therapies to your treatment plan. Assuming you have a good
working relationship with your doctor and that your communication is not
hindered by paternalistic, conservative attitudes, it is much safer to commu –
nicate your thoughts about seeking out alternative therapies with your doctor.
Do not expect a cure from complementary therapies—irrespective of what
you may be told by some alternative health practitioners. What you can hope
for with some of these therapies is that you gain more control over your symp –
toms and hopefully as a result regain more control over how they affect your
life. When used in combination with conventional medicines, they may help
you feel better and live a fuller life.
Before you commit to a complementary therapy, a few words of caution. The
basic principle of conventional treatment that all doctors observe is that you
do not harm the patient. Before you decide to try a complementary therapy,
here are some common-sense suggestions to help you avoid inadvertently
harming yourself:
◆ Get an accurate diagnosis: make sure you know from your doctor specifi –
cally what type of arthritis or musculoskeletal disorder you have, so you
know what you’re treating.
◆ Consult with your doctor: seek your doctor’s advice about the complemen –
tary therapy you are considering and whether there will be any interaction
between the therapy and the medications or other treatments you’re tak –
ing. Always tell your doctor everything you are taking or doing, including
over-the-counter drugs, herbs, vitamins, and special diets or exercises.
◆ Check the therapist’s qualifications: if the therapy is regulated, check whether
the therapist or practitioner has a licence or certificate, or whether they are
certified by a professional organization. Find out what sort of training they
have done and where it was done.

Osteoarthritis · facts
94◆ Consider the time and cost: find out details about costs and how many treat –
ments you’ll need to see some effect. Check whether your health insurance
covers this therapy—arrangements vary between insurers and standard
health cover usually doesn’t include complementary treatments.
Be aware of the danger signs
Some types of complementary therapies are regulated and many practitioners
have high standards of professional ethics and practice. However, others are
not regulated—and unfortunately, not all practitioners are ethical or compe –
tent. Be suspicious of any health professional who does the following:
1. Promises you can be ‘cured’. Many therapies may help your OA, but there
is no cure.
2. Tells you to stop or decrease prescription medicines. Never stop or change
doses of prescription medicines without talking to your doctor.
3. Advises a severely restricted diet. This doesn’t mean a vegetarian diet but a
diet that is extreme or involves eliminating many types of foods. If you want
to follow this route, ask your doctor for a referral to a nutritionally oriented
doctor or to a registered dietitian who will help you plan a well-balanced diet.
4. Insists you pay in advance for a series of expensive treatments. No practi –
tioner can predict how you might respond to a treatment, and you should
not have to pay for treatments you do not receive or need.
5. Cannot show you a licence or a certificate from an approved school or organi –
zation in his or her specialty. Anyone can claim to be an expert—ask for proof!
6. Advises you to keep the treatment a secret from your doctor, or anyone
else. Good medical treatments are not secrets—they are shared in the
medical community. Y our doctor and your spouse or partner (or at least
one member of your family or a good friend) should know the details of
your medical treatment, in case of emergency.
What are the main differences between
conventional medicine and complementary
therapies?
While the different types of complementary therapies have very different phi –
losophies and practices, most share a common view of health and healing:

chapter 9 · Complementary or alternative therapy
95they emphasize ‘wellness’, which they believe comes from a balance between
the body, the mind, and the environment. Illness happens when there is an
‘imbalance’ between these factors.
Conventional (allopathic) medicine tries to treat the specific part of the body
which is ‘faulty’, whereas complementary therapies concentrate on the whole
person—the so-called holistic approach. Each person is treated as a unique
individual who has their own inner resources to fight and overcome illness.
Conventional treatment encourages the patient to remain relatively pas –
sive and to accept their diagnosis and treatment. Complementary therapies
demand that you actively participate in your treatment. The holistic approach
of complementary therapies means you usually have to make more lifestyle
changes (that is, changes to your diet, exercise, and mental attitude) than con –
ventional treatments. This may be key to their continuing success with those
who have tried them.
Both conventional treatments and complementary therapies emphasize the
quality of the relationship between the practitioner and the patient. A good
(open and communicative) relationship is essential for a successful outcome.
How do complementary therapies work?
We all know that the body heals itself, that cuts and wounds heal, and that the
body’s cells are routinely replaced. Complementary therapists believe that this
self-healing is the basis of all healing. Complementary therapy aims to help
the individual get well and then stay healthy. The basic idea is that people ‘heal
themselves’ with the help of a trained practitioner.
What complementary therapies are there?
The main complementary therapies that are used in OA are as follows, in
alphabetical order:
Acupuncture
Acupuncture uses fine needles inserted at precise points on the body. It’s been
used for centuries (originating in China more than 2000 years ago) in Chinese
medicine to restore health for a variety of conditions. Traditional Chinese acu –
puncture is based on the theory that illness can result when the body’s flow
of energy (called chi or qi) is blocked or imbalanced. The acupuncture nee –
dles are positioned to correct those problems. Western medical practitioners
have become interested in acupuncture, especially for pain relief. However,

Osteoarthritis · facts
96they often view acupuncture differently from their peers in traditional Chinese
medicine, focusing on its biochemical effects instead of energy flow. In 2002,
acupuncture was used by an estimated 2.1 million adults in the USA, accord –
ing to the Centers for Disease Control and Prevention’s 2002 National Health
Interview Survey. The acupuncture technique that has been most studied sci –
entifically involves penetrating the skin with thin, solid, metallic needles that
are manipulated by the hands or by electrical stimulation. Recently a number
of well-controlled studies have examined the efficacy of acupuncture for pain
relief in knee OA. In general, these have been supportive of a moderate effect
with most patients demonstrating a 40 per cent decrease in pain, and a nearly
40 per cent improvement in knee function. This may prove to be a very useful
adjunct to other therapies and probably much less damaging than some other
therapies (Figure 9.1).
Aromatherapy
Plant extracts have been used for health and well-being for many centuries. In
aromatherapy, the essential oils are inhaled, massaged into the skin, or used in
a bath. How these oils work is not entirely understood. Some therapists believe
that the essential oil is the ‘soul’ of the plant which has powerful properties to
uplift your spirit as well as help with more fundamental health problems. Each
essential oil is made up of chemical components which are believed to have
individual therapeutic properties but some of these chemicals can be poison –
ous (toxic) in large quantities or can harm people with certain conditions such Figure 9.1 Placement of fine needles at precise points in the knee has demonstrated
efficacy in pain relief

chapter 9 · Complementary or alternative therapy
97as pregnancy or epilepsy. This is why professional aromatherapists have to
understand the chemical components of each oil. There is a scarcity of reliable
data on the efficacy of aromatherapy in osteoarthritis.
Copper bangles
Many people with OA wear copper bangles. Research has shown that people
with OA do have enough copper in their bodies for normal health, so it is dif –
ficult to understand what effect these bangles can have. There is no research
supporting the use of copper bangles (Figure 9.2).
Dietary supplements
Coral calcium
Coral calcium is usually bought in sachets and drunk sprinkled in water. One
company that sells this claims that the residents of the Japanese islands where
it is collected live very long and healthy lives because of the natural elements
in the water, such as calcium, magnesium, and other minerals. Suppliers claim
that tiny particles of coral release these elements when put in water and that
these elements then help the body’s auto-immune system. There has been no
serious research so far into the effectiveness and safety of coral calcium.
Green-lipped mussel extract
Green-lipped mussel extract comes from New Zealand. As with many conven –
tional medicines, several studies found it helpful while other studies showed Figure 9.2 Copper bangle

Osteoarthritis · facts
98no helpful effect. It appears to do no harm, but we do not really know whether
it can help your OA (Figure 9.3).
Herbal medicine
Herbal medicine has been present throughout history. Today about one-
quarter of pharmaceutical preparations contain at least one active ingredient
extracted from plant sources. Whereas conventional medicine tries to isolate
the active ingredient of a plant, herbal remedies use the whole plant. Herbalists
argue that the natural chemical balance in the whole plant has a better effect
on the body than giving a patient just the active ingredient. Herbal treatment
uses plants to try to mobilize the self-healing powers of the body.
Herbal remedies are very popular with some people who believe that they
help to cure different forms of arthritis. Some clinical trials have found some
benefits, but there is not yet enough information about any specific herb to be
absolutely certain about their effects.
If herbal remedies are going to work, you usually need to take them for about
3 months before you feel the full benefit. They are usually safe (non-toxic)
but they may sometimes, like drugs, cause side effects. These side effects can
include nervous depression, irritability, sleeplessness, and even aches and pains
Figure 9.3 New Zealand green-lipped mussels

chapter 9 · Complementary or alternative therapy
99in the muscles or joints. If you are thinking of using these remedies, make sure
you buy them from a reputable manufacturer to ensure product quality.
Homeopathy
Homeopathy is a 200-year-old system of medicine. It is based upon the ‘law
of similars’ (let like be cured by like—so a treatment for nausea might be
a substance that can make you feel sick). The effectiveness of homeopathic
medicines or remedies depends on how they are made. The original, wholly
natural substance is diluted many times in water or alcohol so that only a
few molecules of the original substance may survive in the final remedy. An
important part of this process is agitation of the liquid between dilutions—this
process is thought to maintain the potency of the original substance.
Y ou can easily buy homeopathic remedies over the counter in health food
shops and pharmacies. Homeopathy usually also requires a change in lifestyle
to complement the treatment, which could include changing your diet, more
relaxation, or exercise. Medically qualified homeopaths can also use orthodox
medicine if they wish, as well as the medicines they use in homeopathy. They
can prescribe homeopathy in a truly complementary manner.
Most doctors find that if a chemical drug provides benefits then it can also do
harm if it is wrongly applied or given in the wrong dosage. This rarely happens
with homeopathic preparations. A number of carefully controlled trials have
been carried out with homeopathic medicine, some of them involving arthri –
tis. These suggest that homeopathy can help, but we cannot say if a specific
remedy ‘works’ for hay fever or arthritis. Homeopathic remedies need to be
prescribed on an individual basis, so there is no particular remedy for OA;
rather they are prescribed for the individual who may have OA.
Magnetic therapy
It has been suggested that certain types of magnetic fields can help speed up
healing and reduce pain in muscular complaints. Physiotherapists use equip –
ment which produces a pulsed magnetic field for this purpose. Y ou may also
have seen products such as magnetic bracelets advertised. The manufacturers
of these claim that the magnetic field can increase the ability of the blood to
carry oxygen and waste products and that people with osteoarthritis and other
conditions have reported benefits. However, the bracelets should not be worn
by anyone who has a heart pacemaker fitted. Evidence on whether magnetism
applied in this way can help osteoarthritis is not conclusive at the moment.
Massage
Massage has been around for thousands of years, and was probably first used
in China. Massage can be stimulating or sedating, vigorous or gentle, and

Osteoarthritis · facts
100include the whole body or only parts of it. Oils, creams, lotions, or even tal –
cum powder are used. Massage can reduce your anxiety and stress levels,
relieve muscular tension and fatigue, improve circulation, and thus reduce
pain levels. It is generally very safe and relaxing, and a trained massage thera –
pist will typically follow strict guidelines to avoid endangering patients.
Osteopathy
Osteopathy is a system of manual medicine where the hands are used to diag –
nose and treat a patient. There are no harmful side effects, and osteopaths are
taught to use minimal force. It was developed in the late nineteenth century
by an American doctor, who saw the body as a finely tuned, fully integrated
machine, not as a collection of parts.
Osteopaths believe that a problem with the mechanical structure of the body
will impair its function, but that the body will heal itself if it is given the
right circumstances; that is, a balanced and healthy lifestyle, or the help of
osteopathic manipulation. Ailments such as headaches, skin disorders, and
digestive disorders are seen as the results of spinal misalignment. Osteopaths
believe that their manipulation of the muscles and joints helps the body to
combat illness and heal itself.
Reflexology
Reflexology is a treatment in which varying degrees of pressure are applied
to different parts of the body to promote health and well-being. It suggests
that every part of the body is connected by reflex zones or pathways which
terminate in the soles of the feet, palms of the hands, ears, tongue, and head.
Reflexology suggests that tension, congestion, or some other imbalance will
affect an entire zone and that it is possible to treat one part of the zone to
change another part of the body. Gentle pressure is thought to help detoxifica –
tion and promote healing. It can be very relaxing, and thus diminish pain, but
there is no evidence to suggest it can directly affect your OA.
Conclusions
Complementary therapies can play an important role in encouraging posi –
tive changes in lifestyle and outlook, such as increased self-reliance, a positive
attitude, relaxation practices, and appropriate exercises. Lifestyle changes like
these may help to improve the pain and other symptoms stemming from OA.
Currently a cure for OA is not possible, and these changes can be as impor –
tant as more conventional treatments.

10110
Medicines used in
osteoarthritis
% Key points
◆ The medicines available today are predominantly used to treat the
symptoms and not to cure osteoarthritis.
◆ Although some medicines are beneficial in relieving the symptoms
associated with osteoarthritis, they can carry unwanted side effects.
◆ It is important to understand the role medications can play in the
management of your osteoarthritis, to discuss this with your doctor,
and to use them alongside the other strategies in the management of
osteoarthritis.
◆ Injections can lead to substantial reductions in pain. They should be
administered by a trained practitioner, and used alongside other strat –
egies for managing pain.
◆ Glucosamine sulphate, chondroitin sulphate, and some vitamins are
widely used in the field of osteoarthritis. Although the evidence of
their efficacy is limited, they are well tolerated by most patients.
◆ Recent data have raised doubts on the potential effects of vitamin D
supplements in the treatment of knee osteoarthritis, but more research
is needed.
◆ It is therefore the responsibility of each person to understand the
mechanism, dose, and potential side effects behind each preparation
before deciding to take any of these, or not.

Osteoarthritis · facts
102There are many medicines used to help in the management of osteoarthritis,
but sadly so far there is no ‘magic tablet’ that can cure the condition. The
medications available are aimed at reducing the unpleasant symptoms that
OA causes, such as stiffness and pain.
There is a vast array of medications and food supplements (some of them
licensed as medicines in some European countries) on the market in this field.
This includes not only tablets but also injections.
The general approach by doctors is that using medication in conjunction with
other management strategies such as weight loss, exercising, and pacing is the
most beneficial approach. The aim of this chapter is to give an overview of the
medicines most commonly used in OA and how they should be taken.
In what forms are medications available?
With advances in technology, there are many different ways that medications
can be taken. In OA the most common mode is by mouth, in either tablet
form or liquid, as this is the most convenient, cheapest, and also the least inva –
sive route (when compared to injections or suppositories). It also allows the
person more control of the administration of the medicine. Some strong pain-
relieving medicines come in patch form, and there are also some medicines
used in OA that can be administered in the form of creams.
Some treatments, such as corticosteroids and hyaluronic acid supplements,
can be given by injection directly into the joint.
Medicines used outside their licence
All medicines that are available on prescription have gone through rigorous
compulsory stages of research and development during which time the drug
is registered for a specific licence for a specific use. However, it is not uncom –
mon for doctors to use drugs outside their licence in their practice if there is
research to support it.
How to take the medication
Many people are not happy to take medication long term, either because they
are concerned about side effects, or because they are worried about becoming
dependent on the drug, and many people simply do not like to take tablets.
For these common reasons many people take their medication as and when
they need it, and usually when the pain becomes severe. This often leads to
peaks and troughs in pain levels, which results in having to take a higher dose

chapter 10 · Medicines used in osteoarthritis
103of the painkillers in order to reduce the high levels of pain. All tablets have a
time limit as to how long they are effective for and this can vary from drug
to drug: taking your medication on a regular basis will prevent the pain from
spiralling out of control. Some people find in doing this that they can take
smaller doses of the medication. By taking the medication on a regular basis
you will hopefully find that you can take control of the pain rather than the
pain controlling you.
Pain-relieving medicines in general (analgesics)
There are many analgesics for pain in general on the market today and this
alone can be quite baffling. Some are called by the generic name, some use
the manufacturer’s brand name, and some can contain more than one drug.
In general, there are three main groups of analgesia, which are categorized
according to their strength. The easiest way to demonstrate this is to use a
ladder model (see Figure 10.1): the higher up the ladder, the stronger the
analgesia.
The first rung of the ladder—non-opioid drugs
Generally speaking most people with osteoarthritis take medication from
this group of drugs. However, it is important to know that although they are
classed as medicines used for mild pain this does not mean they have mild side
effects. Taken in the correct dosage, paracetamol is safer than the medications
that follow, however the non-steroidal anti-inflammatory drugs (NSAIDs) can
have some serious unwanted side effects, such that they are used sparingly in
people who have osteoarthritis.
The middle rung of the ladder—weak opioid drugs
If the drugs designed for mild pain are unhelpful your doctor may suggest
trying a drug from this group. As suggested by their title, these drugs are
Morphine, diamorphine, fentan yl, bupr enorp hine, tramadol
Codeine, dih ydrocodeine, co-d ydramol, co-c odamolWeak opioid drug s for mild to mo derate pain
Non-opioid drugs for mild pain
Parace tamol, NSAI DSStrong opioid drug s for severe pain
Figure 10.1 The analgesic ladder
Adapted with permission from World Health Organization, WHO Analgesic Pain Ladder , available
from <http://www.who.int/cancer/palliative/painladder/en/>

Osteoarthritis · facts
104weak versions of opioids (opioids are derived from the poppy which produces
opium). They are either manufactured on their own or combined with par –
acetamol. Unfortunately the side effects of opioids can be unpleasant and
can involve constipation, confusion, reduced cognitive function (slow thought
processing), and hallucinations and insomnia, and hence are not always popu –
lar with patients. Some physicians find it useful to prescribe them in slowly
increasing doses to monitor and minimize such side effects.
The top rung of the ladder—strong opioid drugs
As their title suggests, these are the strongest opioids: they can be either
synthetic or natural. Some drugs in this group are available in the form of a
patch worn by the patient, but most are available to take orally. These drugs
have greater analgesic properties, but the unwanted side effects can also be
enhanced to such a degree that they outweigh any benefits. For some patients,
especially the elderly, the side effects could heighten the risk of falling. With
all opioids there are concerns about dependency, and for this reason only the
very mild form of opioids are available over the counter: stronger opioids are
prescribed by your doctor following a full assessment.
People who take regular opioids should always be reviewed regularly by
their prescribing doctor to monitor the effects, but it is equally important to
seek clinical advice if you find that the dose of these strong opioids starts to
escalate.
Starting your medication
Doctors will initially choose a mild form of analgesia to help with the pain
and stiffness caused by osteoarthritis, and many people with this condition
find that the drugs from the bottom rung of the ladder are adequate enough.
However, if this fails to control the pain, either an increased dose or a stronger
analgesia may be chosen using the ladder approach (Figure 10.1). There are
many different types of analgesics in each group, and if one fails to help then
the doctor may try another drug from that group. Unfortunately it is often the
case that the higher up the ladder one goes, the more severe and unpleasant
the side effects can be, and for many this can outweigh the benefits of taking
the drug. It is therefore important to discuss the use of these drugs with your
doctor.
Common medicines used in osteoarthritis
We will now look at the most common drugs used in the management of
osteoarthritis.

chapter 10 · Medicines used in osteoarthritis
105Paracetamol/acetaminophen
This is the recommended first-line drug of choice for mild to moderate pain
caused by osteoarthritis. It is a safe drug to use so long as the maximum dose
is not exceeded (traditionally 1 g up to four times a day—4 g in total). It is
important to note that due to safety concerns some countries including the
USA are suggesting that the maximal dose be 3.2 g per day. It is not an anti-
inflammatory drug but is an analgesic. The side effects are infrequent but can
include constipation and bleeding for some people. There are some groups of
people who should avoid using it, for instance, those who have liver failure.
Long term it is considered to be a safe drug to use, although some studies
have found mild indigestion with a prolonged daily dose of 4 g. It is important
to note that many flu remedies contain paracetamol and so it is important to
read the small print to avoid overdosing.
Non-steroidal anti-inflammatory drugs (NSAIDs)
◆ Arthrotec®
◆ Aspirin
◆ Diclofenac
◆ Diflunisal
◆ Fenbrufen
◆ Ibuprofen
◆ Indometacin
◆ Ketoprofen
◆ Ketorolac
◆ Meloxicam
◆ Nabumetone
◆ Naproxen
◆ Piroxicam
◆ Sulindac
◆ Tenoxicam.

Osteoarthritis · facts
106Should paracetamol fail to help the pain in moderate to severe OA pain,
NSAIDs are considered. These are anti-inflammatory drugs but they are not
steroids (as the title suggests), they are also analgesics. They are useful in the
management of osteoarthritis because of a combination of their analgesic and
anti-inflammatory properties. They are effective in relieving osteoarthritic
pain for many people, although long-term studies have shown paracetamol to
be equally effective.
NSAIDs are considered to be a mild analgesic; however, this does not neces –
sarily mean they have mild side effects. In fact NSAIDs are a group of drugs
that should be used with caution in the treatment of osteoarthritis due to the
side effects which include reduced kidney function, gastric tract (the stomach
and small intestine) bleeding, and ulceration which could be fatal. They have
been shown to increase the chance of a myocardial infarction (heart attack) in
prolonged use in patients who already have other risk factors for heart disease
(see later in this section). Recent data have suggested that even a short-term
use of NSAIDs can increase the risk of heart attacks in patients with a previ –
ous history of myocardial infarction or angina.
The reason NSAIDs are associated with such side effects is their mode of
action. Prostaglandins are naturally produced in the body and are responsible
for the inflammatory response to an injury or a disease. NSAIDs act by reduc –
ing the production of prostaglandins, relieving pain in these diseases.
However, prostaglandins have also beneficial effects for our organism: for exam –
ple, they help to produce a natural protective lining for the gastric tract (the
stomach and small intestine) from the body’s own corrosive gastric acid that is
produced to digest food. That is why NSAIDs, by blocking the production of
the gastric tract’s protective fluid, can cause heartburn and gastric discomfort.
NSAIDs are also influential in cardiovascular events as they can increase
blood pressure and so cause hypertension, which can predispose a patient to
heart attacks.
There are some groups of people in whom NSAIDs should be used with
extreme caution as the risk of side effects can be increased:
◆ Those aged over 60 years.
◆ Those with a history of peptic (stomach/duodenal) ulceration.
◆ Those on warfarin or blood-thinning agents.
◆ Those taking corticosteroids.

chapter 10 · Medicines used in osteoarthritis
107◆ Smokers.
◆ Those with a history of cardiovascular disease.
◆ Those with high blood pressure.
◆ Those who drink more than three units per day of alcohol.
◆ Those who have poor health in general.
There are several different groups of NSAIDs and within each group there
are numerous tablets. There is not always any rhyme or reason as to why a
particular NSAID will help one person but not suit another, and often the
patient may have to try a few until the most beneficial one is found. However,
it is very important not to administer more than one type of NSAID at any
one time, as this would increase your risk of severe side effects dramatically.
The advice given to people who take NSAIDs is to take the lowest possible
dose for the shortest possible time and to take them with or after food. They
should stop taking them immediately if gastric pain or upset occur. Some cli –
nicians also co-prescribe a gastric protector with the NSAIDs to help protect
the gastric tract, and some NSAIDs already come in a combined preparation
with a gastric protector: for example, Arthrotec® contains misopristol (a gas –
tric protector). Some people find that NSAIDs can exacerbate their asthma
and they should be avoided if this is the case.
NSAID creams/gels
These have been found to be beneficial in hand or knee osteoarthritis but not
so effective for hip osteoarthritis, probably due to the inability for the cream
to penetrate so deeply. Although there have been reports of serious gastric
side effects with NSAIDs, the cream has a good safety record. Unfortunately
many people find that the benefits of the cream can wane, and it is thought
it may play a role in managing pain during a flare-up as opposed to using it
long term. Common side effects can include itching and rash but this usually
disappears when use stops.
Selective Cox-2 inhibitors (celecoxib, etoricoxib,
lumaricoxib, and other -coxibs)
These are also NSAIDs, but unlike the NSAIDs discussed earlier they are
less likely to cause gastric upset. The Cox-2 enzyme is responsible for inflam –
mation but not for the production of gastric protection: inhibiting the Cox-2
enzyme can reduce inflammation but gastric protection is not altered. These

Osteoarthritis · facts
108are newer drugs than the NSAIDs and although they are safer than NSAIDs
with regard to gastric side effects, unfortunately they are no safer with regard
to the cardiovascular system, and over recent years we have seen the with –
drawal of Vioxx® (rofecoxib) from long-term use for this reason. As with tra –
ditional NSAIDs, this group of drugs can be very effective for pain relief in
people with osteoarthritis but it is important to weigh the risks of unwanted
side effects with the benefits. This has become even more relevant recently
since it was shown that patients with osteoarthritis have an increased risk of
cardiovascular diseases.
It is thought that they are relatively safe for short-term use but they are not
desirable for long-term use, and there are groups of people in whom they
should be used with extreme caution:
◆ Those with a history of heart disease or who have had a stroke.
◆ Those with a family history of heart disease.
◆ Those with hypertension.
◆ Those who smoke.
◆ Those with diabetes.
Amitriptyline and duloxetine
Despite actually being antidepressants, duloxetine is used for the treatment
of chronic pain in patients with knee osteoarthritis, and amitriptyline is most
effective in treating sharp stabbing-type pains that are caused by nerves (the
so-called ‘neuropathic pain’).
Amitriptyline was indeed originally licensed for the treatment of depression
when taken in high doses; however, it was later found to have beneficial effects
for reducing pain when taken in lower doses (10–50 mg) and today is pre –
scribed to many people with osteoarthritis alongside the analgesics mentioned
in this chapter. It is a drug that should be taken on a regular basis for it to be
effective, as benefits are not always seen for a few days/weeks. It is often pre –
scribed to be taken at night (2 hours before bedtime) as one of the side effects
is sleepiness: taking the drug in this way means the side effect can be used to
help have a good night’s sleep! Some people develop a hung-over feeling for
the first few days of starting it and clinicians often therefore advise people to
take it in very small doses and gradually build up the dose until benefits are
felt and side effects minimal. During this period you need to ensure that you

chapter 10 · Medicines used in osteoarthritis
109are safe to drive or operate machinery and your doctor will be able to give
guidance on this. The dose needed can vary from person to person, but the
most common drug doses are between 10 and 50 mg each night. Side effects
can include a dry mouth and some people can develop water retention or
weight gain. This drug is a prescription-only medication and there are some
people for whom it is not recommended, for example, those who have glau –
coma or abnormal heart rhythms. Similarly there are some drugs with which
it is contraindicated.
Duloxetine is a ‘dual’ (serotonin norepinephrine reuptake inhibitor) anti –
depressant, but it was approved by the Food and Drug Administration (an
agency that is responsible for the regulation of the use of medicines in the
USA) for the treatment of chronic pain in patients with knee OA in 2010.
Recent data have confirmed the efficacy of duloxetine in patients with knee
OA who have moderate or severe pain despite treatment with NSAIDs.
Common side effects of duloxetine include nausea, headache, dry mouth,
diarrhoea or constipation, dizziness, fatigue, somnolence, insomnia, and
decreased appetite.
Capsaicin cream
This is derived from the seeds and membranes of the Nightshade family of
plants, which includes the pepper plant, and it acts by desensitizing the nerves
that carry the pain messages to the brain. It has been shown to be a safe medi –
cine to use either in conjunction with other analgesics or on its own. It can be
prescribed in differing strengths and to achieve maximum benefit it should be
applied three to four times a day.
Due to its origin it is common following the first application to experience
pain, burning, redness, and sometimes irritation to the area where the cream
is applied, but this usually settles following further applications. Due to the
nature of the side effects it is recommended that hands are washed immedi –
ately following application and that the cream is kept away from the eye and
not allowed in contact with broken skin. It is thought to have few side effects
other than the local skin reactions already mentioned and approximately 20
per cent of people who use it find it effective.
Strontium ranelate (SR)
Although it is only licensed for its use in the treatment of osteoporosis (brittle
bones), some studies suggesting a potentially beneficial effect in osteoarthritis
led to a recent trial in patients with this condition. SR is thought to improve
the quantity and quality of the bone laying below the articular cartilage, and

Osteoarthritis · facts
110that is the way it could improve symptoms and reduce progression/worsening
with time in OA patients.
A recent international study compared the effects of SR to placebo in a total
of 1371 patients with knee OA: SR appeared more effective in reducing both
knee pain, and radiographic worsening over 3 years of follow-up.
Although these results were promising, the European Medicines Agency
did later publish a safety alert, as they found that in previous studies SR
could increase the risk of cardiovascular events. This is now being studied,
and further recommendations will be notified to clinicians in the next few
months.
Specific therapies for erosive hand OA
EULAR guidelines (2007) have recognized the importance of treating ero –
sive hand OA as a separate entity. However, the specific treatment options
are scarce. Small trials including a few patients with erosive hand OA have
shown some beneficial effects for a number of drugs including clodronate
and hydroxychloroquine. However, the costs and safety of these therapies in
patients with hand OA remain largely unknown, and more research is clearly
needed in this field.
Injection therapies
Injections are used to help in the management of osteoarthritis, but they are
not a cure for the condition. They act by reducing symptoms such as pain and
discomfort with the aim of improving function once more. As with other med –
icines, they should be used as part of a package, for example, alongside exer –
cising, losing weight (if overweight), and pacing. The injections that we will
cover in this chapter are called intra-articular injections—injections directly
into the joint itself. They are therefore very different to the usual intramuscu –
lar injections (e.g. the flu jab) or subcutaneous injections (e.g. those used to
administer insulin). There are two intra-articular injections commonly used in
the management of osteoarthritis:
◆ Corticosteroid injections
◆ Hyaluronic acid.
This chapter will cover these two injections and look at how effective they are,
who they are suitable for, and potential side effects.

chapter 10 · Medicines used in osteoarthritis
111Corticosteroid intra-articular injections
Corticosteroids are hormones that are either produced naturally by the adre –
nal gland (found above the kidney) or produced synthetically. Most injection
preparations are synthetic. They have various metabolic functions, but are
used in osteoarthritis because of their potent ability to reduce inflammation.
They were first used in the 1950s and to date most studies have concentrated
on the knee joint, although there are some indications that it may also be
beneficial for hips. The vast majority of the research conducted with the knee
joint confirms that corticosteroid injections are beneficial when compared to
a placebo treatment. Today approximately 53 per cent of doctors use these
injections to help alleviate the pain caused by osteoarthritis.
It is thought that corticosteroid injections are most beneficial in those people
who are having a flare-up of pain and/or who have an effusion (swelling) of the
knee. The EULAR (European) guidelines recommend that these injections
should be used for people with a flare-up of knee pain who fail to respond to
conventional NSAIDs or other analgesia. There are some people for whom the
injection would not be suitable, for example, those with bleeding disorders,
those taking anticoagulants, and those who have a skin infection or ulcers.
Also, these injections should be used with caution in patients with a history of
heart attacks or stroke, as well as in diabetics.
As mentioned earlier, the corticosteroid injection is not a cure for osteoar –
thritis but it can help relieve the pain and inflammation. The onset of pain
reduction is usually rapid (between 24–48 hours) with the maximum effect
being reached within a few days. Studies have shown that the benefits last up
to 4 weeks in most subjects and up to 3 months in some patients who have
effusions of the knee. They can be repeated up to four times per year for the
knee joint although usually less often for hand joints. Research to date has
not shown repeated injections to cause any deterioration of osteoarthritis in
humans.
It is the responsibility of the doctor to discuss any potential complications
prior to any procedure. As with any injection into a joint, there is always a
risk that infection could be introduced which can cause septic arthritis. The
risk of this is thought to be relatively low (1:14,000), but it is a risk nonethe –
less which can result in increased symptoms and, rarely, death. It is therefore
important that the injections are performed by a qualified doctor who is aware
of the sterile technique required.
It is not uncommon following the injection to have a temporary, mild flare-up
of knee pain occasionally accompanied by some inflammation. This is due to a

Osteoarthritis · facts
112natural reaction of the synovial fluid in the joint to the crystal steroid solution
of the injection. It is usually an immediate side effect but it is not permanent,
and the treatment for this is a cold compress.
Following the injection there is also a small risk of developing depigmentation
(loss of skin colour) and or/fat atrophy (wasting) around the injection site, the
risk of this can vary with different steroid preparations. Some people who have
diabetes may find following the injection that their blood sugar levels rise in
the first few days and so need to monitor blood sugar levels and adjust diet/
medication accordingly.
Temporary facial flushing may rarely occur following the administration of the
steroid injection and there is the potential risk of anaphylaxis (allergic reac –
tion), although this is very rare.
Most clinicians recommend patients to rest in the 24 hours following any
intra-articular injection to reduce the risk of complications.
Hyaluronic acid
Hyaluronic acid is a naturally occurring component of the synovial fluid and
is also found in the cartilage. It is highly viscous and acts as a shock absorber
within the joint. It also stores energy that can be released when there is rapid
joint movement and acts as a lubricant when there is slower movement. It is
thought that it has a role in maintaining a healthy cartilage. In the osteoar –
thritic joint there is less naturally occurring hyaluronic acid and it can be less
viscous.
By injecting hyaluronic acid directly into the joint the depleted levels are
replenished and hence ease the pain and improve function of the joint. The
early regimen of administering hyaluronic acid was by weekly injections for
3–5 weeks, although newer preparations require only one or two injections
per course.
Again, most research has been focused on the knee joint and has found this
treatment is most beneficial for those with mild-to-moderate osteoarthritis. It
has also been shown that the presence of swelling may predict a poor response
to this injection. Further studies are needed to evaluate if they are effective for
the hip joint and the shoulder joint, although early indications are that it may
be beneficial for osteoarthritis of the shoulder.
Hyaluronic acid injections are not a cure for osteoarthritis, but they are
used to help reduce the symptoms (pain, swelling, stiffness). The ben –
efits are usually noticed between 2 and 5 weeks, although this can vary,

chapter 10 · Medicines used in osteoarthritis
113and flatten out between 5 and 13 weeks. The benefits usually last about 6
months and are similar in magnitude to that of NSAIDs. However, although
a high number of studies have been performed, differential effects have
been observed for different products available and on different variables
and at different timepoints, making pooled analyses difficult and leading
sometimes to controversial results. Therefore, more data are required before
making general recommendations on the use of hyaluronic acid injections
for osteoarthritis.
Short term, there have been no reported complications using hyaluronic acid,
but studies are still needed to establish long-term effects of its use and to
examine if there are any anatomical benefits/disadvantages. Like all intra-
articular injections, there is a small risk of infection in the joint.
Immediately following the injection one can experience increased pain, and
up to 10 per cent of people can develop increased pain, swelling, and hotness
of the joint following the first or second injection. This may vary accord –
ing to the type of preparation used, but it is thought that this may occur as
an immune response to the injection contents and/or due to the technique
used, for example, the angle of the knee or needle. The side effects are usu –
ally short-lived and treatment usually consists of a cold compress, rest, and
analgesics.
Glucosamine, chondroitin, vitamins, and other
supplements
Today in both Europe and the USA, there are vast numbers of health food
shops and mail order companies promoting herbal supplements and vitamins
which they claim can improve our general well-being and also help specific
conditions such as osteoarthritis. Doctors and nurses are frequently asked
‘Will supplements help with my osteoarthritis?’, and although there has been
extensive research with their use in some diseases, to date research in the field
of osteoarthritis is lagging behind. All conventional medicines go through
extensive research and vigorous regulatory controls before being licensed
and are closely monitored with regard to their efficacy and safety profile after
being licensed for use in patients. This enables doctors to review the literature
and establish the overall health benefits of each drug. Supplements, however,
do not have to abide by such rigorous controls, making it difficult for doctors
to give advice regarding many of the supplements that are available today. The
aim of this section is to provide information regarding the most frequently
used supplements available today for osteoarthritis with the research that we
have available. It is thought that there are three main areas where supplements

Osteoarthritis · facts
114can play a role in either improving symptoms or preventing further progres –
sion of osteoarthritis:
1. Preventing oxidative damage.
2. Preventing or repairing damaged cartilage.
3. Reducing inflammation.
An oxidant is an oxidizing agent that can potentially be damaging to its sur –
rounding structures. In the joints oxidants are produced by the chondrocytes
(cells in the cartilage): they target the main structure in the connective tissue
of the joint (collagen) and depolarize the lubricant (the hyaluronate fluid) in
the joint. Oxidants are therefore unwanted visitors to the joint.
Glucosamine and chondroitin
These are the two leading supplements in the field of osteoarthritis today, and
rank third in the top-selling nutritional supplements in the USA. It is thought
that one or another of these products is used by 5–8 per cent of US adults.
In most of Europe they are available only with prescription (as a medicine);
however, in the USA and the UK they can be obtained via health food shops,
in supermarkets, and via home catalogue shopping companies. In the latter,
they can be found in a combined formulation or be bought separately. As with
many medications, supplements, and treatments they may not be beneficial
for everyone, and it is necessary to have a trial period of about 3 months if
they are to be taken for pain relief.
Glucosamine
There are two types of glucosamine available:
1. Glucosamine sulphate
2. Glucosamine hydrochloride (a formulation suitable for vegetarians).
Glucosamine sulphate naturally occurs in the body, but the commercially
available preparations are derived from shell fish such as crab, lobster, and
shrimp shells: if you have an allergy to shellfish it should be avoided, and
vegetarians may choose glucosamine hydrochloride as an alternative. The rec –
ommended daily dose of glucosamine sulphate is 1500 mg per day: patients
should be aware that over-the-counter medications vary the dose strength of
each tablet. Patients who take glucosamine sulphate generally find the pain
relief takes longer to achieve than regular NSAIDs, varying between 2 weeks

chapter 10 · Medicines used in osteoarthritis
115and 3 months, with the latter probably the most common duration. The pain-
relieving effects can also last for up to 3 months after stopping it. Most of the
research conducted has used glucosamine sulphate and has tended to focus on
patients with osteoarthritis of the knee. Although not all studies have shown
benefit in pain relief over and above a dummy tablet (a placebo), the majority
have shown it to be effective in reducing pain over prolonged periods of time
with pain relief consistent with mild anti-inflammatory medication. There is
also emerging evidence that it may reduce the loss of cartilage in patients with
knee OA and eventually reduce the need for knee replacement surgery if taken
long term.
There is less research on glucosamine hydrochloride; however, early results
from a large US study failed to demonstrate any significant benefit.
It is thought that glucosamine sulphate is a safe supplement to take but there
are three groups who should be careful if considering it:
◆ Those allergic to shellfish would be advised to avoid it due to a possible
allergic reaction.
◆ It should be avoided in pregnancy or if breastfeeding due to a lack of
research regarding its safety for the baby and mother.
◆ There have been some concerns in the past that glucosamine may raise
blood sugar levels in those who have diabetes, although studies to date
have dispelled this. However, it is wise to closely monitor blood sugar lev –
els while taking glucosamine if you have diabetes and to avoid its use in
patients with unstable diabetes.
Chondroitin
Chondroitin sulphate is also a naturally occurring substance found in the
body and is a part of a protein that gives cartilage its elasticity. The prepara –
tions for sale commercially can be derived from one of three sources:
◆ Avian
◆ Bovine
◆ Shark.
It is thought to have similar effects to that of glucosamine sulphate in that it
can reduce the pain levels and also play a role in the formation and repair of
cartilage in mild-to-moderate osteoarthritis. A number of studies have been

Osteoarthritis · facts
116performed, and although they do not universally demonstrate significant pain
relief over and above placebo, overall it appears to induce pain relief to a simi –
lar degree as glucosamine sulphate. Again there is early evidence that it may
prevent further cartilage loss and hence prevent disease progression in patients
with knee osteoarthritis. The recommended dose to take is 800 mg per day.
It too has a good safety record, although like glucosamine it should not be
used in pregnancy or if breastfeeding, as no studies have been conducted with
these groups of people. It is also suggested that those people who take blood-
thinning agents, such as heparin, warfarin, or aspirin, should have their clot –
ting time monitored. Chondroitin has a similar structure to heparin and so
could cause bleeding in some people.
Vitamins
Some vitamins are antioxidants whose role it is to suppress the oxidants pre –
sent in the joint from causing joint damage and thereby help to relieve the
symptoms of osteoarthritis. Most vitamins are to be found in a well-balanced
diet and in fact are absorbed better by ingesting them in this way as opposed
to taking supplements. The three main vitamins thought to be involved in
relieving osteoarthritis are vitamins C, D, and E.
Vitamin C
Vitamin C is an antioxidant and therefore counteracts the oxidants that dam –
age the cartilage. It has also been shown to play a role in the production of the
collagen that is present in cartilage, and this has been supported by a study
that revealed those with a low level of vitamin C had a poorer quality of carti –
lage. Vitamin C is present in fruit and vegetables and it is recommended that
we all have five portions of these a day.
Vitamin E
It is thought that vitamin E acts in an anti-inflammatory role in the osteoar –
thritic joint and therefore may be effective in reducing pain, although the data
is conflicting regarding its benefit.
Vitamin D
Vitamin D has an extensive role to play in the bones and joints: most research
has been conducted in the field of osteoporosis where its benefits are substan –
tial. Vitamin D affects most components of the joint including bone, carti –
lage, and muscle, and may therefore have multiple effects on its structure and

chapter 10 · Medicines used in osteoarthritis
117function. The majority of vitamin D is produced in the skin in response to
exposure to sunlight, although it is also absorbed from food. With the increas –
ing, and appropriate, adoption of sun-avoidance behaviour, the rates of vita –
min D deficiency, especially in the elderly, are substantial and rising.
Research has found that those subjects with a low dietary intake of vitamin
D, or low levels in the body, have an accelerated progression of the disease.
However, a recently published study including 146 patients with knee osteo –
arthritis randomized to vitamin D supplements or placebo has shown limited
benefits on knee pain, function, and no benefit on disease progression after 2
years of follow-up.
Other supplements
There have been small studies on a number of less common supplements and
their effects on osteoarthritis, some of which have been positive, but more
research is necessary. These supplements include the avocado and soya bean,
S-adenosylmethionine (SAM-e), and ginger.
Conclusion
Many people find analgesics are very effective. Pain is a unique experience to
each person and therefore the choice of analgesia that suits one person may
not always be beneficial for everyone. It is important to note that many of the
analgesics carry with them unwanted side effects as well as benefits, and it is
the responsibility of each individual, given the relevant information, to decide
whether the benefits of taking the medication outweigh the side effects. We are
all too often aware of new concerns and discoveries with some of the medica –
tions and the long-term side effects that they can have and in recent years we
have seen media reports and the withdrawal of some medications. Research
and monitoring of drugs is always ongoing for our own safety and is the nature
of progressive medicine. It is hoped that in future years scientists may be able
to improve the safety of the drugs that many people find beneficial.
It is recognized that intra-articular injections can have a role to play in the
management of osteoarthritis, in particular of the knee. These injections are
used widely in the USA and Europe in the management plans of patients
who have osteoarthritis. Corticosteroids are useful for those who have an
effusion or flare-up of the pain and who are not able to take NSAIDs. They
have a quick onset for symptom relief but they also have a shorter dura –
tion period. Hyaluronic acid injections are useful for those with mild-to-
moderate osteoarthritis—they have a slower onset but a longer duration of
action. Unfortunately they are more costly and entail up to five injections

Osteoarthritis · facts
118at weekly intervals for maximum benefit. With either of these injections it
is important to be treated by a qualified and experienced practitioner to
achieve maximum benefit. It is also important to remember to use them as
part of a package including analgesia, pacing, exercising, and keeping to a
healthy weight.
Many of the nutritional supplements available today claim to have benefits for
those with osteoarthritis, but it is important to remember that the research in
this field can be scanty and poorly conducted compared to the vigorous field
of conventional medicines. Dietitians would agree that most vitamins can be
acquired through a healthy diet of fresh fruit and vegetables, fish oils, and
natural sunshine, and that overdosing could occur if unnecessary supplements
are taken above the required diet.
Although some clinicians are not convinced of the benefits of glucosamine
and chondroitin in relation to osteoarthritis, in general they have a high safety
record and it is accepted that these two supplements can be considered for
those with osteoarthritis. Each individual is responsible for what they choose
to take and are advised to research their benefits before investing in this field.
Medications used in other diseases should not be stopped without first dis –
cussing this with your doctor.

119There are several simple and inexpensive techniques that can be successfully
used to help reduce the pain, stiffness, and other symptoms of OA.
Heat and cold
The decision to use either heat or cold should be discussed with your doctor
or physiotherapist. Moist heat, such as a warm bath or shower, or dry heat,
such as a heating pad, placed on the painful area of the joint for about 15
minutes, may relieve the pain and reduce joint stiffness. An icepack (or a bag
of frozen vegetables) wrapped in a towel and placed on the sore area for about
15 minutes may help to reduce swelling, tenderness, and stop the pain. If you
have poor circulation, do not use cold packs (Figure 11.1).11
Device use
and other therapies
for osteoarthritis
management
% Key points
◆ There are many simple devices or gadgets available that can improve
your ability to walk, bathe, cook, clean, and dress.
◆ Typically they help avoid putting stress on your joints with osteoar –
thritis and they also help to decrease pain and improve your overall
function.
◆ Y our doctor, physiotherapist, or occupational therapist can advise you
as to which may be suitable.

Osteoarthritis · facts
120Transcutaneous electrical nerve stimulation
(TENS)
A small TENS device that directs mild electric pulses to nerve endings that
lie beneath the skin in the painful area may relieve some arthritis pain. TENS
seems to work by producing high-frequency electrical stimulation of the nerve
which disrupts pain messages to the brain and by modifying pain perception.
Ambulatory assist devices
Consider a cane, used in the hand contralateral to the painful joint, if you have
persistent ambulatory pain from hip or knee OA. A cane reduces loading force
on the joint and is associated with a decrease in pain in patients with hip and
knee OA. If you have OA in both legs (not just one) then to distribute load
evenly it may be preferable to use a walker/frame.
To use this, stand comfortably and erect with your weight evenly balanced on
your walker. Move your walker forward a short distance. Then move forward,
lifting your leg so that the heel of your foot will touch the floor first. As you
move, your knee and ankle will bend and your entire foot will rest evenly on
the floor. As you complete the step, allow your toe to lift off the floor. Move the
walker again and your knee and hip will again reach forward for your next step.
Remember, touch your heel first, then flatten your foot, and then lift your toes
off the floor. Try to walk as smoothly as you can. Dont hurry (Figure 11.2).
These should be available through consulting an occupational therapist, visit –
ing a medical device shop, and frequently can also be found in pharmacies.
Figure 11.1 Application of heat or ice to an affected area can greatly facilitate pain
relief

chapter 11 · Device use and other therapies for osteoarthritis management
121Knee braces
The importance of mechanical factors in the development of OA may explain
why knee OA occurs more often in the medial compartment, presumably due
to its increased loading during gait. Despite the apparent important role of
mechanics in the aetiology of knee osteoarthritis, few therapies have attempt –
ed to ameliorate the forces responsible for disease. Two therapies that have
attempted to modify these forces are knee braces and heel wedges.
Since involvement of the medial compartment is especially frequent, interven –
tions whose goal is to realign the knee so as to reduce loading on the medial
compartment, such as valgus bracing, are used clinically. For those with insta –
bility of the knee, there is evidence that valgus bracing and orthotic devices
shift the load away from the medial compartment, and, in doing so, may pro –
vide considerable relief of pain and improvement in function.
Wedged insoles
One way of lessening load across the medial compartment would be to insert
an insole into the shoe that alters the distribution of load in the foot that in
turn alters load at the knee. In particular, lateral wedge insoles (lateral aspect
higher than medial) increase hindfoot valgus in an attempt to straighten out
the leg, and produce less medial knee loading (Figure 11.3).Figure 11.2 Walking sticks/canes, crutches, and a walking frame

Osteoarthritis · facts
122Japanese investigators have invented and tested such a wedged insole for treat –
ment of medial osteoarthritis and have suggested that when wedged insoles
are used, there is an increasing valgus angulation of the calcaneus that pro –
duces a more upright leg with less medial knee loading.
The symptomatic effect of wedged insoles has been evaluated in a number
of uncontrolled studies and more recently a number of controlled trials. The
earlier studies suggested that wedges provided short-term symptomatic ben –
efit. The randomized controlled trials dont demonstrate a benefit in terms of
symptom relief and suggest it may make pain in the hip/back worse. In sum,
despite some supportive evidence the strongest evidence would suggest these
have little if any benefit for osteoarthritis pain.
In contrast to this finding, if you have lateral knee osteoarthritis (between tibia
and femur in the lateral compartment of the joint) a medial wedge has been
found to be beneficial for symptoms.
Knee bracing
The concept of a valgus brace is to apply, during weight-bearing, a moment
to the knee, which directly opposes the usual adduction moment and thus
reduces load on the degenerative medial compartment. Figure 11.4 shows
one of the examples of a valgus brace on a right leg, which functions through
three-point bending.
A number of biomechanical studies have demonstrated an improvement in
many aspects of gait with valgus bracing in knee OA. Some studies of the
effectiveness of unloader braces for the treatment of varus knee OA have also
Laternal heel wedg e
Righ t shoe
Figure 11.3 A lateral heel wedge (right shoe)

chapter 11 · Device use and other therapies for osteoarthritis management
123been reported. These studies demonstrate that wearing a valgus brace gives a
clinically significant and immediate improvement in the pain and function of
patients with medial osteoarthritis of the knee. The valgus brace group signifi –
cantly reduced their pain by approximately 50 per cent at 12 weeks and this
was maintained at 24 weeks. To put this improvement in symptoms into con –
text, most studies of anti-inflammatories suggest they relieve about 15–20 per
cent of pain. Newer brace designs may facilitate greater compliance as cur –
rently the efficacy of braces is limited to the time for which they are worn—
they were often large, bulky, and difficult to wear under clothes—so adherence
to their use has been a problem. Despite this they appear very effective for
pain and the newer brace designs may overcome many of the shortcomings of
older brace technology.
If the predominant site of your knee osteoarthritis involvement is the joint
between the kneecap (patella) and femur there are different braces that may
be of help (Figure 11.5).Figure 11.4 External abduction moment applied by a medial hinge brace, which can
‘push’ the knee into valgus

Osteoarthritis · facts
124Figure 11.5 A brace designed for persons with arthritis of the joint between the
kneecap (patella) and femur
Figure 11.6 The application of patella taping has been shown to improve symptoms
in knee OA

chapter 11 · Device use and other therapies for osteoarthritis management
125Patella taping
Physiotherapists tape the knee as short-term or intermittent treatment for
knee pain. Knee taping is believed to relieve pain by improving alignment of
the patellofemoral joint and/or unloading inflamed soft tissues. A recent trial
found that therapeutic taping of the knee is efficacious in the management of
pain and disability in patients with OA (Figure 11.6).
Braces for the hand
Splinting of the first carpometacarpal joint (base of thumb), preferably with
prefabricated neoprene, can be facilitated by an occupational therapist or pos –
sibly purchased over the counter. The thumb splint can be worn full-time until
an acute episode settles, or alternatively only worn during performance of
aggravating activities (Figure 11.7).
Other assistive devices
There are many simple devices or gadgets available that can improve your
ability to walk, bathe, cook, clean, and dress. Because they help avoid putting
stress on your joints with OA, they also help to decrease pain and improve
your overall function.
Figure 11.7 A hand brace

Osteoarthritis · facts
126Y our doctor, physiotherapist, or occupational therapist can advise you as to
which may be suitable.
Examples of these devices include the following:
◆ Wheels on rubbish bins, items of furniture, or anything else that has to be
moved. A wheeled cart or island in the kitchen can help you move food
from cooktop to tabletop.
◆ Extenders on chair legs can raise the seat at the kitchen or dining room
table to the height at which its easiest for you to sit.
◆ Wide-grip foam handles on utensils can make them easier to grip.
◆ Lever-style handles on doorknobs and kitchen taps will avoid the need to
grip and twist knobs.
◆ A reach extender—a rod with trigger-controlled grasp at the end—will let
you pick up small, out-of-reach objects.
◆ Shoes with hook and loop fasteners instead of shoelaces will make dress –
ing easier.
◆ Clothes that do up at the front, or with big buttons, make it easier to dress
and undress.
◆ Sheets with Velcro tabs on the corners of sheets make it easier to make the
bed without tucking in the sheets.
◆ Lamps that turn on with a touch, or are activated by your voice or motion,
will avoid the need to use switches.
◆ For the bathroom, consider tap turners (lever-style handles), a bath bar
(to hold on to as you get in and out of the bath), and an elevated toilet
seat.

127While most people with osteoarthritis won’t need surgery, it might be an
option for you if you experience severe joint damage, extreme pain, or very
limited motion as a result of your OA and other more conservative treat –
ments have been unsuccessful. The decision to use surgery depends on several
things including your level of disability, the intensity of pain, the interference
with your lifestyle, your age, other health problems, and your occupation.
Currently, more than 80 per cent of the surgeries performed for osteoarthritis
involve replacing the hip or knee joint. Y our general practitioner, together with
an orthopaedic surgeon (a doctor who specializes in surgery on bones and
joints) can assist you in determining if surgery is an option for you to relieve
the pain from osteoarthritis.12
Surgical therapy
% Key points
◆ If conservative treatments have not been successful and you experi –
ence pain and limited motion then surgery may be a therapeutic
option for your osteoarthritis.
◆ The postoperative rehabilitation process is often lengthy, and compli –
cations are possible—please give the decision to have surgery appro –
priate consideration.
◆ Although some complications (such as wound infection) are more
common in the obese, the benefits of surgery are high also in obese
patients. Therefore, joint replacement is not contraindicated for obese
patients.
◆ A discussion with your doctor and then an informed decision aware of
the potential risks and benefits of surgery should be made.

Osteoarthritis · facts
128Surgery may be performed to:
◆ remove loose pieces of bone and cartilage from the joint if they are causing
pain or symptoms of buckling or locking
◆ resurface (smooth out) articular cartilage and bones
◆ reposition bones (osteotomy)
◆ replace joints.
The benefits of surgery may include improved movement, pain relief, and
improved joint alignment. Of course, there are always risks to surgery, espe –
cially if you have other health problems or you are overweight, which can add
stress to the heart and lungs during surgery. There also is the risk of blood
clots forming in your legs.
If you are thinking about having surgery for your osteoarthritis there may be
lots of questions on your mind. This chapter aims to provide the most up-to-
date information on the options available and to answer the questions which
people most often ask, such as: when should I have surgery? What surgical
options there are? What complications may arise?
When should I have surgery?
Surgery should be resisted when symptoms can be managed by other treat –
ment modalities. If your function and mobility remains compromised despite
maximal medical therapy (this includes non-medicinal approaches such as
weight loss, exercise, and bracing as well as medicinal approaches such as
taking analgesics), and/or if your joint is structurally unstable, you should be
considered for surgical intervention. If your pain has progressed to unaccep –
table levels—that is, pain at rest and/or night-time pain—you should also be
considered a surgical candidate. Thus the typical indications for surgery are
debilitating pain and major limitation of functions such as walking and daily
activities, or impaired ability to sleep or work despite other therapy.
Y ou are an ideal surgical candidate if you have not yet developed appreci –
able muscle weakness, generalized or cardiovascular deconditioning (loss of
bodily and heart function), your body mass is normal, and you can medi –
cally withstand the stress of surgery. To ensure the best return of joint func –
tion after surgery, surgery should be performed before your arthritis causes
complications such as marked muscle loss. Furthermore, before undergoing
surgery you should be in the best possible physical condition and be prepared
for rehabilitation after surgery. It is due to this that a number of guidelines

chapter 12 · Surgical therapy
129recommend that surgery should be considered before there is prolonged and
established functional limitation and severe pain.
Full functional recovery after surgery may not be realistically expected if you
have significant cognitive impairment, such as dementia, or symptomatic car –
diac (heart) or lung disease, since these conditions can impede postoperative
rehabilitation.
What surgical options are there?
There are several different types of joint surgery. We discuss those most com –
monly used for people with osteoarthritis.
Arthroplasty/joint replacement
Surgery may be used to replace a damaged joint with an artificial joint.
Development of modern total hip arthroplasty in the 1960s by John Charnley,
a British surgeon, represents a milestone in orthopaedic surgery. Joint replace –
ment is an irreversible intervention used in those for whom other treatment
modalities have failed. Arthroplasty, or joint replacement surgery, is most
often done to repair hips and knees, but also is used to repair shoulders,
elbows, fingers, ankles, and toes. Currently the most common indication for
knee (total knee replacement or TKR) and hip replacement (THR) (approxi –
mately 85 per cent of all cases) is osteoarthritis. Each year, approximately
300,000 TKR surgeries are performed in the USA for end-stage arthritis of
the knee joint. Over 30,000 knee replacement operations are carried out each
year in England and Wales, and the number is increasing.
Joint replacement is one of the most successful procedures available in mod –
ern medicine, but still has its risks and potential complications. We discuss
next the procedure itself, its potential risks, and benefits.
What happens during joint replacement?
During joint replacement surgery, the surgeon first removes all the damaged
bone and cartilage from the joint. Surgeons may replace affected joints with
artificial joints called prostheses. These joints can be made from metal alloys,
high-density plastic, and ceramic material. Surgeons choose the design and
components of prostheses according to their patient’s weight, sex, age, activity
level, and other medical conditions. They can be joined to bone surfaces by
special cements. Artificial joints can wear out and about 10 per cent of artifi –
cial joints may need replacing again.

Osteoarthritis · facts
130For younger people who are more active or for older people who have strong
bones, doctors sometimes use artificial joints that do not require cement to
stay in place (Figure 12.1). These artificial joints are designed with spaces into
which the person’s own bone can grow, holding the artificial joint in place
more naturally. By avoiding the use of cement, which can weaken over time,
these types of artificial joints usually stay in place longer than those that are
held in place with cement. In patients younger than age 55, alternative surgi –
cal procedures, such as osteotomy and unicompartmental knee replacement,
deserve consideration.
Recovery from joint replacement surgery depends on several factors, includ –
ing a person’s general health and level of activity before the surgery. For this
reason, it is not a good idea to put off the surgery for long. The more active
you are before your surgery, the faster your recovery is likely to be. Most peo –
ple who have a hip or knee replaced will need physical therapy to help regain
their mobility. A physical therapist will recommend special exercises to help
you build up the muscles around your new artificial joint. Physical therapy
starts in the hospital shortly after surgery and continues after you are home.
What complications can arise?
A replacement joint can never be as good as a natural joint. Y ou are still likely
to experience some difficulties in movement. Although complications from
joint replacement are rare, the new joint can become infected or slip out of Before Afte r
Figure 12.1 A prosthesis is a device designed to replace a missing part of the body,
or to make a part of the body work better. The metal prosthetic device in knee-joint
replacement surgery replaces cartilage and bone that is damaged from disease or ageing

chapter 12 · Surgical therapy
131place. For this reason, your doctor will ask you to come in regularly for check –
ups so that they can monitor your healing and recovery.
Any operation on the lower limbs can lead to a small blood clot forming in the
leg. To reduce the risk of blood clots, your doctor may prescribe anti-clotting
medication. If a clot develops it is usually treated with blood-thinning medi –
cines such as heparin or warfarin. In a very small number of cases the blood
clot can travel to the lungs (pulmonary embolism), which leads to breathless –
ness and chest pains.
Joint replacement surgery may also cause bleeding and infection in the peri –
od just after surgery. The use of preoperative antibiotics and other operating
room procedures reduces the risk of deep wound infections after replacement
surgery to less than 1 per cent.
Loosening of the attachment between the hardware and bones may also occur
and require removal and replacement of the artificial joint. Debris caused by
wear of the plastic or metal sometimes causes inflammation and may also
require reoperation to correct if the replacement becomes loose.
An extreme case of an adverse reaction to metal debris related to joint replace –
ment is the so called ‘pseudo-tumour’ seen in some patients who received
a THR (especially ‘metal-on-metal’ prostheses), a mass lesion that can be
locally invasive around the hip joint. Patients who have this usually complain
of discomfort in the groin or buttock, a swelling in the hip, or a sensation
of clicking or ‘giving way’ of the hip. More research is needed on the causes
and best solutions for this issue, but published data have shown no additional
concerns for patients who received a metal-on-metal hip prosthesis but have
no symptoms.
Removing and replacing an artificial joint is more difficult than the initial sur –
gery and has a higher risk of complications, especially of infection. Because
of the limited life of artificial joints, people with osteoarthritis are generally
encouraged to wait as long as possible before having replacement surgery. Age
younger than 55 at the time of replacement surgery, male gender, obesity, and
presence of comorbid conditions are all risk factors for revision.
Proper surgical technique, surgeon’s experience, and the choice of prosthesis
(device designed to replace part of the body) may have important influences
on surgical outcomes. One of the clearest associations with better outcomes
appears to be the higher procedure volume of the individual surgeon and the
procedure volume of the hospital. Overall the risk of death, usually due to a
heart attack, a stroke, or a blood clot reaching the lungs, is about 1 in 200 (0.5
per cent), but this risk varies between patients and hospitals.

Osteoarthritis · facts
132What are the options for joint replacements?
Total joint replacement
Most joint replacement operations involve a total joint replacement, which
means that both sides (compartments) of the joint are replaced.
Unicompartmental replacement
If arthritis affects only one side of your knee—usually the inner side—it may
be possible to have a half-knee or unicompartmental replacement (sometimes
called hemiarthroplasty). The unicompartmental operation is only suitable for
about one in four people with knee osteoarthritis. This is a less extensive opera –
tion than a TKR and it should therefore mean a quicker recovery (Figure 12.2).
Kneecap replacement
It is possible to replace just the kneecap (patella) and its groove (trochlea)
if this is the only part of your knee affected by arthritis. This is also called
One compart ment /T_hree compa rtment
Figure 12.2 Figure depicting unicompartmental (one) replacement versus total
knee replacement—replacement of both tibiofemoral and patellofemoral (kneecap)
compartments

chapter 12 · Surgical therapy
133a patellofemoral replacement or patellofemoral joint arthroplasty . Again this is a
less major operation with speedier recovery times. The operation is only really
suitable for about 1 in 10 people with knee osteoarthritis.
Who should have their joint replaced?
To be a candidate for joint replacement you should have radiographic evi –
dence of joint damage, moderate to severe persistent pain that is not ade –
quately relieved by an extended course of non-surgical management, and clin –
ically significant functional limitation resulting in diminished quality of life.
Joint replacement surgery dramatically relieves pain in people with severe oste –
oarthritis of the hip or knee, and this benefit appears to last for up to 30 years.
However, it may take up to 1 year before the benefits of joint replacement sur –
gery become fully apparent. Joint replacement is an elective procedure, and the
risks and outcomes vary. Therefore, it is essential that you be informed of the
likely consequences of the surgery in terms that are specific to you. Everyone’s
goals and expectations (i.e. hopes and fears) should be considered before
surgery to determine whether these goals are attainable and the expectations
realistic. Any discrepancies between your expectations and the likely surgical
outcome should be discussed in detail with the surgeon before surgery.
There are few absolute contraindications for joint replacement other than
active local (where the joint is replaced) or systemic infection (infection else –
where such as urinary tract infection or pneumonia) and other medical condi –
tions that can substantially increase the risk of serious operative complications
or death. Severe peripheral vascular disease and some neurological impair –
ments are both relative contraindications to joint replacement.
With proper patient selection, good to excellent results can be expected in
95 per cent of patients, and the survival rate of the implant is expected to be
95 per cent at 15 years. When overall health improvement is used to assess
the cost-effectiveness of total joint arthroplasty, the hip and knee arthroplasty
have similar results. Costs associated with long-term medication, assistive care
and decreased work productivity may exceed the cost of arthroplasty.
It should be noted that joint replacement is more cost-effective among patients
who had the most to gain (those with lower preoperative function). However,
if left until functional status has declined, the postoperative functional status
does not improve to the level achieved by those with higher preoperative func –
tion. Please don’t defer the surgery until your function is too impaired; for
example, if you are wheelchair- or bed-bound for a long time before the sur –
gery your postoperative recovery will be very difficult and prolonged.

Osteoarthritis · facts
134Obesity is not a contraindication to joint replacement; however, there may
be an increased risk of delayed wound healing and perioperative infection in
obese patients. On this basis, some healthcare systems might be tempted to
either postpone or even deny surgery to obese patients, but recent data sug –
gest that obese patients undergoing total knee or hip replacement benefit from
surgery at least as much as non-obese people.
What happens in hospital?
Preoperative visit
If you and your doctors agree you should go ahead with a joint replacement
operation you will usually be invited to a preoperative assessment clinic some
time before your planned admission date. At this visit you will be assessed by
a doctor or nurse to see if you are generally fit enough to cope with the opera –
tion. This will involve a number of tests. Usually samples of blood are taken
to check that you are not anaemic and that your kidneys are working properly.
A urine sample will be taken to rule out infection. Y our blood pressure will
be recorded and an electrocardiograph (ECG) tracing will be carried out to
make sure your heart is healthy. At this visit you should have the opportunity
to ask any questions about your operation or discuss anything you are con –
cerned about.
There is a general consensus that preoperative heart-risk assessment should
be performed and heart and lung function should be optimized before sur –
gery. If there is any underlying heart or lung disease this should be treated
preoperatively. Smoking cessation can reduce the risk of cardiac events and
postoperative pneumonia and should be recommended for all smokers preop –
eratively, although it may need to be initiated at least 2 months before surgery
for optimal effect. Among patients older than age 70, preoperative assessment
of mental status with a standardized instrument such as the Mini Mental
Status Exam (MMSE) can help to identify patients at high risk for confusion
at the time of the operation. Postoperatively, incentive spirometry (breathing
exercises) should be used to reduce the incidence of pneumonia. Preoperative
patient education about what will happen during surgery and the postopera –
tive period has been shown to improve patient outcomes, including reduced
use of pain medications, reduced anxiety, and improved patient satisfaction.
Going into hospital
Y ou will probably be admitted to hospital on the day of your operation or the
evening before. Y ou will be asked to sign a form consenting to surgery, and
your joint will be marked for the operation.

chapter 12 · Surgical therapy
135Anaesthesia
The operation will be performed under a general or spinal anaesthetic so that
you feel no pain.
The operation
This usually takes between 45 minutes and 2 hours, depending on the com –
plexity of the surgery.
After the operation
Before going back to the ward you will spend some time in the recovery room.
Here you may be given more fluids and drugs, such as painkillers, through the
tube in your arm. Y ou may be given a switch so that you can administer pain –
killers to yourself at a safe rate according to how much pain you feel. Oxygen
therapy is likely to be given through a mask or through tubes into your nose. If
necessary you will be given a blood transfusion.
Getting mobile again
After the first day or so, the various tubes giving painkillers, fluids, or oxygen
therapy will be removed and, with the help of nursing staff and physiothera –
pists, you should be able to start walking. The length of time it will take you
to become mobile will vary according to your circumstances and the outcome
of your operation.
Generally, if you have had a spinal anaesthetic or nerve block you will have
very little feeling in your leg for the first day or two. Y ou may have a tube
(catheter) inserted into your bladder for a few days to help you pass water,
especially if both knees have been replaced at the same time.
At first you will need crutches or a frame to walk. Y our physiotherapist will
be able to advise you on climbing stairs and other activities and should also
explain the exercises you will need to do in order to keep improving your
mobility in hospital and at home.
Going home
It is usually possible to go home as soon as your wound is healing well and you
can safely walk to and from the toilet, get dressed, and manage stairs with the
help of crutches or a frame. Most people are fit to go home between 4 and 9
days after surgery, but it may be longer in some cases.

Osteoarthritis · facts
136Before you leave hospital do ask your occupational therapist or physiothera –
pist about the best ways to get dressed, take a bath, get in and out of bed, and
use the toilet, and about any dressing or bathing aids that you may need. This
is especially important if you have had both knees replaced at the same time.
Follow-up appointments
Y ou will usually have a follow-up hospital appointment about 6 weeks after
your operation to check on your recovery.
When will I get back to normal?
Obviously it will be some weeks before you recover from your operation and
start to feel the benefits of your new knee/hip joint. Y ou can make a big differ –
ence to how quickly you become mobile again by making sure you follow the
advice of your hospital team and keeping up your exercises. Y ou should make
sure you have no major commitments—including long-haul air travel—for the
first 6 weeks after the operation. Gradually you will be able to build up the
exercises to strengthen your muscles so that you can move more easily and
independently. Y ou will probably need painkillers as the exercises can be pain –
ful at first. Y our physiotherapist or occupational therapist should advise you on
these tasks but here are a few pointers:
◆ W alking. It is important at first that you do not twist your knee/hip as
you turn around. Take small steps instead. It should be possible to walk
outside about 3 weeks after your surgery but make sure you wear good
supportive outdoor shoes.
◆ Going up and down stairs. When going up the stairs use the handrail and
hold your crutch or crutches in your free hand. First put your unoperated
leg onto the step, place your crutches on the stair with your free hand,
then move your operated leg up. When you go down the stairs, it is the
other way round. Put your unoperated leg down first with your crutches,
followed by your operated leg.
◆ Sitting. Make sure you do not sit with your legs crossed for the first 6 weeks.
◆ Sleeping. Y ou do not have to sleep in a special position after knee surgery,
as you would after a hip replacement. However, you should avoid lying
with a pillow underneath your knee. Although this may feel comfortable it
can result in a permanently bent knee.
◆ Driving. If you were driving before your operation, you should be able to drive
again after about 6 weeks if your joint replacement was carried out by the
conventional method, or about 3 weeks if you had minimally invasive surgery.

chapter 12 · Surgical therapy
137Other surgical options
Arthroscopic treatment
Arthroscopy, or ‘scoping’ a joint, is an outpatient procedure that is used to
examine and sometimes repair joints. For arthroscopy, the doctor inserts a
viewing tube (an arthroscope) through a small cut (about 5 mm or ¼ in) into
the fluid-filled space in the affected joint. The technique can be used to help
with diagnosis or to carry out treatment or keyhole surgery using miniaturized
instruments.
In arthroscopic debridement the surgeon clears away debris and smooths
damaged cartilage in the knee. The role of this type of arthroscopic surgery
of the knee for osteoarthritis is controversial. However, for a small subgroup
of knees with loose bodies or flaps of meniscus (disc of cartilage in the knee)
or cartilage that are causing mechanical symptoms, such as locking, or catch –
ing of the joint, arthroscopic removal of these unstable tissues may improve
joint function and alleviate some of these mechanical symptoms. Although
this surgery may provide temporary relief of symptoms, it does not stop the
progression of arthritis. Thus a selected group of patients with osteoarthritis
may benefit from arthroscopy. However, if there is already a lot of osteoar –
thritis, it may be better to do another type of surgery rather than arthroscopy.
Arthroscopic debridement (clearing away debris and smoothing the cartilage
in the knee) is still commonly performed in people with knee osteoarthritis
but is used less frequently nowadays as evidence of its lack of benefit accrues.
In the absence of locking or catching symptoms this surgery will be as effective
as taking a placebo (such as a sugar pill). Y ou are still placed at risk of opera –
tive complications such as infections and leg clots. If this surgery is offered to
you by your surgeon, please question its true benefits for management of your
symptoms, and balance these against the real risks of complications (discussed
later in this chapter).
Osteotomy/realignment
Surgery may be used to realign bones and other joint structures that have
become misaligned because of long-standing osteoarthritis. For the knee, such
realignment may shift weight-bearing to healthier cartilage where the joint has
been unevenly damaged by the osteoarthritis, with resulting pain relief. The
procedure is done to relieve stress on the cartilage and prevent further damage
to the joint. During an osteotomy, the surgeon removes a small wedge of bone
near the affected joint. Removing the piece of bone realigns the bone and
improves the contact between the remaining, healthy areas of cartilage in the

Osteoarthritis · facts
138joint. The tibial osteotomy for the knee may be recommended for a younger,
active patient instead of joint replacement surgery.
Typically this intervention leads to improvements in pain and function. Recovery
is typically prolonged, but osteotomy may delay the need for total joint replace –
ment for 5–10 years. This may allow a knee replacement to be postponed, but it
can also make the subsequent replacement of your knee more difficult if a knee
replacement were to be needed later on. Currently there is debate as to the rela –
tive merits of osteotomy versus unicompartmental knee replacement.
Arthrodesis/fusion
A surgical procedure called arthrodesis, or joint fusion, is sometimes used
to correct severe joint problems caused by osteoarthritis. In this procedure,
the surgeon makes the affected joint permanently immobile by using a bone
graft and inserting metal screws, plates, and rods to hold the joint in place.
Arthrodesis is performed only when the pain from osteoarthritis is so severe
that immobilizing the joint is an improvement. This may be recommended for
badly damaged joints for which joint replacement surgery is not an option.
Fusion may be recommended for joints of the wrist and ankle and the small
joints of fingers and toes but is rarely recommended for knees or hips. Joint
immobility in large joints such as the knee and hip leads to marked impair –
ments in function and should be avoided unless this procedure is absolutely
necessary (Figure 12.3).
Knee
arthro scope
incision site s
Arthro scope
Patell a Instrument s
Figure 12.3 Typical incision sites for knee arthroscopy

chapter 12 · Surgical therapy
139Cartilage grafting/transplantation
Unlike bone, cartilage that is injured does not rejuvenate. Surgery may be
used to graft new cartilage cells into damaged regions of cartilage. The bene –
fits of cartilage grafting in arthritic joints is still being studied. Cartilage graft –
ing is likely to be most practical when the cartilage damage is confined to a
very small area surrounded by normal cartilage. Current techniques are not
helpful for people with large areas of thin or absent cartilage, as is typically the
case in osteoarthritis.
Cartilage transplantation uses live cells from donated cartilage. This process is
known as autologous chondrocyte therapy (ACT) or autologous chondrocyte
implantation (ACI). Another technique, called mosaicplasty, involves moving
cartilage and some bone from another part of the knee to repair the damaged
surface. Graft procedures combining these two techniques may be used to
cover larger areas of joint damage. The donated cartilage must be transplanted
within 72 hours. The risks of bleeding and joint infection following surgery
Wedge
removed
PlateClosin g
wedg e
Figure 12.4 The knee during osteotomy with removal of wedge (top left) and after
closure with application of plate

Osteoarthritis · facts
140are probably similar to those with joint replacement. Both mosaicplasty and
ACT/ACI may be more widely used in the future, though it is not possible to
be certain of this yet, and their role in management of osteoarthritis today is
limited. They have shown promise in persons who have a small focal defect
(full-thickness cartilage loss with an area less than 2 square cm)—the majority
of people with symptomatic osteoarthritis typically have widespread damage
through the joint making this procedure more technically difficult and the
results less favourable. There is no point in undergoing an experimental surgi –
cal procedure if the chances of success (marked improvement in symptoms) Figure 12.5 Technique for autologous chondrocyte implantation (ACI). A defect is
prepared so that it is surrounded by normal, healthy cartilage. A small flap of soft tissue
(periosteum) is removed from the tibia to be used as a cover flap. This periosteum is
sewn over the defect, and treated with a sealant (fibrin) to avoid leakage of injected
cells. Cartilage precursor cells (chondrocytes at an earlier stage of development)
harvested at a previous surgery and grown for 6 weeks (called ‘chondrocytes’) are
injected beneath the flap
Adapted from Karlsson J. (ed), Knäledens sjukdomar och skador , Astra Läkemedel, Södertälje,
Sweden, Copyright © AstraZeneca 2000.

chapter 12 · Surgical therapy
141are negligible. There is currently a great deal of research being conducted in
these and other tissue-engineering techniques that may prove effective long
term. Until they do (in the absence of being involved in a research study)
please resist the temptation of having this therapy (Figures 12.4 and 12.5).
Other surgical options
There are several other techniques that are occasionally offered to people
with arthritis. One such procedure is microfracture. This operation, which
is performed by keyhole surgery, entails making holes in the bone surfaces
with a drill or pick to encourage new cartilage to grow. The benefits are not
well proven and the results are not as good as knee replacement for advanced
arthritis.
Conclusion
Please recognize that surgery is not the first line of treatment for OA and
should generally only be recommended once other more conservative modes
of treatment have been tried and not helped.
In choosing a surgeon to do your operation, ideally select someone who comes
well recommended and does this surgery regularly—patients of higher-volume
specialist surgeons have better outcomes and fewer complications.

143The one thing that we all have in common is that we experience thoughts and
emotions in our daily lives. These thoughts and emotions can be both nega –
tive and positive, and are part of the way we process events in our lives. There
are many thoughts and feelings that we can experience when diagnosed with
a chronic condition such as osteoarthritis. Thoughts such as: why me? Why
can’t I be cured? Will I end up in a wheelchair? How will I cope? These can
create unhelpful emotions such as anger, fear, and worry. We can feel frus –
trated at not being able to do some simple tasks, grieve at losing hobbies and
interests, and feel guilty asking others to help with chores, sometimes resulting
in a feeling of helplessness or worthlessness.
For some people these thoughts and feelings are normal responses to receiv –
ing the news that they have osteoarthritis. For many they are not ongoing
and so do not play a major role in their lives. However, for some people these
thoughts and feelings can persist and in so doing, become more unhelpful
and impact on the way osteoarthritis is managed, and also increase the pain 13
Depression and coping
% Key points
◆ Thoughts and emotions play a part in our everyday lives.
◆ There is a close relationship between chronic pain (as in osteoarthri –
tis) and depressed mood.
◆ It is natural for people with osteoarthritis to have some negative
thoughts which may cause anxiety and occasionally depression.
◆ Anxiety and depression can be successfully addressed with an array of
treatments.
◆ If these emotions are not addressed it becomes more difficult to man –
age the osteoarthritis.

Osteoarthritis · facts
144experience. Our thoughts and feelings are as important as the disease process
itself and should not be seen as a weakness.
What are thoughts?
Throughout our day when we are engaged with something, our brain is having
thoughts. A thought can be described as something we are saying in our head,
for example, ‘I think they like me’, ‘The chocolate cake looks delicious’, ‘Do
I look fat in this?’! Thoughts can be both negative and positive in their nature
and affect the way we feel about ourselves.
What are emotions?
Emotions (feelings) are the result of the thoughts that we have. There are many
different negative and positive emotions that we can experience: for example,
joy, happiness, sadness, fear, worry, anger, and jealousy are just a few. Y ou may
feel elated if others like you, or feel guilty eating the chocolate cake.
Behaviours
Our feelings affect the way that we behave: for example, if the thoughts on
going to the dentist are positive—he will make my teeth white—then we are
more likely to go on a regular basis for check-ups. However, if the thought of
the dentist’s chair causes a feeling of fear then our behaviour may be quite dif –
ferent, you may only go when you get severe toothache!
‘Nobody li kes me ’
‘Depressio n’ Becomes withdraw n and isolated
Fuels initial thoughts/T_hought
Emotion
Does n’t go ou t, avoi ds talking to peop leBehaviou rCons equences
Figure 13.1 Common thoughts and emotions when diagnosed with osteoarthritis

chapter 13 · Depression and coping
145How thoughts, emotions, and behaviour
are related
Thoughts affect our emotions, which affect our behaviour. The way we behave
then affects our thought process and so a vicious cycle starts (Figure13.1).
Common thoughts and emotions when
diagnosed with osteoarthritis
For some people the diagnosis of osteoarthritis can be a relief: ‘I thought I
had a life-threatening condition’, ‘People will understand now why I have the
pain’. However, for many in the early stages following the diagnosis of osteo –
arthritis, there are unhelpful emotions of anger, denial, and worry.
Anger
People can be angry for various reasons: we can feel angry that we have the
condition and that there is no cure, angry with the doctors, angry that we can –
not pursue interests and hobbies, and angry that the osteoarthritis is intruding
in our lives.
Denial
Initially we can deny that we have osteoarthritis—‘It only happens to others’, or
‘I think this is something else’. As time goes by, this denial makes it difficult to
put management strategies into place. If left, it can lead to reduced functioning.
Worry
There are many concerns and questions that people have when first diagnosed
with osteoarthritis: ‘Will it get worse?’, ‘I will not be able to manage’.
Depression and anxiety
If these unhelpful thoughts just mentioned are not addressed they can lead to
more unhelpful emotions such as depression and anxiety. These two emotions
are well recognized in many people who are living with a chronic condition
such as osteoarthritis. There are also some people who have depression and
anxiety prior to this diagnosis.
Depression and osteoarthritis
The type of depression that we shall discuss here is unipolar, as opposed to
bipolar depression (manic depression). Unfortunately depression is still a

Osteoarthritis · facts
146condition that people do not like to talk about, but this is not to say that it
is not common. It is thought that 19 per cent of the general population have
depression and that up to one-third of people who have osteoarthritis have
some degree of depression: it is therefore a relatively common condition seen
by doctors. Research has shown that if you experienced depression before the
age of 40 then you are more likely to experience depression again with the
onset of chronic pain, such as that experienced in osteoarthritis.
What are the signs and symptoms?
It is part of human nature to have good days and low days, but this alone does
not lead to a diagnosis of depression: it is thought that 65 per cent of the popu –
lation experience low mood at some time in their life. Most of us will probably
recall a time in the past 2 weeks of feeling ‘fed up’ for a short time and some
would say it is an essential part of our make-up to have some lows in our lives
in order for us to experience the highs! Depression, like pain, is a very personal
experience to each individual but generally consists of a persistent unpleasant
feeling of despair and sadness. The severity can vary from mild where the per –
son can experience feelings of down-heartedness, to severe where the person
can lose all confidence, have no self-worth, and have thoughts of wanting to
end their life. Health professionals will diagnose depression if:
◆ Y ou have been feeling low in your mood and/or have lost interest and
pleasure in things every day for the past 2 weeks PLUS:
Four of the following symptoms most days, over the past 2 weeks:
◆ Feeling of fatigue and loss of energy (loss of motivation to carry out enjoy –
able tasks, daytime sleeping).
◆ Unable to sleep at night, and/or early waking (not due to pain) or exces –
sive sleeping during the day.
◆ Irritability (snappy with friends and family).
◆ Reduced concentration or inability to make decisions (could be a work or
at home).
◆ Loss or increase of appetite or weight (weight loss, comfort eating).
◆ Feelings of excessive guilt or worthlessness (‘I am not a good parent’, ‘I
can’t do anything’).
◆ Morbid thoughts (suicidal or self-harming thoughts).

chapter 13 · Depression and coping
147If you feel having read this list that you have the symptoms of depression then it is
important to go and discuss it further with your doctor.
The effects of depression on osteoarthritis
As already mentioned, our thoughts and feelings affect our behaviour. If left
untreated, depression can increase the amount of pain and discomfort we feel as
a result of osteoarthritis and can affect the way we manage our lives. Figure 13.2
demonstrates this.
It is important to recognize and treat depression and to break this vicious cir –
cle. Having depression is not a sign of weakness—it is a normal reaction to an
unwanted situation, such as being told that you have osteoarthritis.
Anxiety
What is anxiety?
Anxiety is a natural human response to certain situations. Many of us experi –
ence anxiety when visiting the dentist, parents experience a certain amount of
anxiety when watching their children reciting at a school concert, and soldiers
feel anxious before going into battle. Anxiety is a natural protective mechanism
that prepares our body for dangerous or uncomfortable situations where we
may need to fight or flee (stay and confront or run away). It is thought that this
stems back to the days when survival was an everyday part of life: physiological
changes were necessary to help us run from a lion, or wolf, or to fight with bears!
My life is mi serable with OA
Feels depressed Becomes less f it, pain levels incr ease,
social is olation
Cannot be bo thered
Slows down, diﬀ iculty sleepling and ea ting
Figure 13.2 The effects of depression on osteoarthritis

Osteoarthritis · facts
148Anxiety itself is therefore not a problem, as it helps us to survive and deal
with certain situations. However, it can become troublesome when there is
no longer an imminent danger present, but you still feel anxious and experi –
ence the symptoms of anxiety. Specific types of anxiety which include phobias,
panic attacks, and general anxiety disorders require specialist treatment and
so will not be discussed in this book.
The signs and symptoms of anxiety
When we experience anxiety in response to a perceived threat our body releas –
es a hormone called adrenaline (also called norepinephrine). Adrenaline has
many actions on different parts of the body with the aim of preparing us for
fight or flight. Physical symptoms of anxiety can be identified in Figure 13.3.
Anxiety and osteoarthritis
It is not uncommon for anxious people to expect the worse, worry about
things before they happen, and worry that they will not be able to cope. The
Pale skin
SweatingEye vision
Dry mouth
Heart be ats faster
Butter flies
Pins and needle s
Aches inmuscles
Figure 13.3 The physical effects that anxiety can have on the body

chapter 13 · Depression and coping
149worrying thoughts of those who have osteoarthritis, including ‘Why me?’ and
‘I won’t be able to cope’, can lead to unacceptable levels of anxiety. Such
thoughts cause the body to jump into action and release adrenaline and then
the body develops the symptoms of anxiety. For people who have long-term
pain due to osteoarthritis, the physical effects of anxiety are very unhelpful
(Figure 13.4).
Treatment for depression and anxiety
There are treatments and things that you can do yourself to help manage these
unhelpful thoughts and feelings. The different types of treatment consist of:
◆ Education
◆ Medication
◆ Counselling
◆ Cognitive behaviour therapy
◆ Relaxation.
Ideally, combinations of treatments work best. It is important to discuss the
available treatments with your doctor, who is skilled at identifying your level
of anxiety and or depression and will know what would be the best treat –
ment plan.Muscle fatigue as a result of anxiet y
Long periods of rest
Decr ease in general fitness
Increased pain
More anxiet y as the symptoms incr ease
Figure 13.4 The effects of anxiety on osteoarthritis

Osteoarthritis · facts
150Education
It has been shown that the more information we have about a chronic condi –
tion the more successful we are at managing it. People with osteoarthritis who
suffer from depression or anxiety can benefit greatly from health professionals
who provide information on the condition. It is helpful to understand what
osteoarthritis is, how it develops, signs and symptoms, and its natural progres –
sion. This can help deal with some of the anxieties that we may have. Some
centres offer clinics and helplines with the aim of providing information about
all aspects of osteoarthritis. Some of these educational sessions are held in
groups while others are offered on a one-to-one basis.
In some areas, you may have access to pain-management programmes, which
deal with the management of chronic pain conditions, including osteoarthri –
tis. These programmes are run by a team of different health professionals and
address thoughts and feelings as key components in managing pain. They are
geared to managing the pain as opposed to curing it, and have been shown to
be beneficial.
The Internet has opened up a whole new source of information. There are
several websites available regarding osteoarthritis, which can provide use –
ful information. It should be said, however, that clinicians recommend
that these websites are chosen with caution as some can be misleading or
inaccurate. Y ou will find some useful addresses at the end of this book in
Appendix 2. Information regarding osteoarthritis can also be gained from
recognized groups such as the ARC (Arthritis Research Campaign) and
OARSI (Osteoarthritis Research Society International). These provide very
accurate and useful leaflets and contacts.
Antidepressants for depression and anxiety
For moderate to severe depression, medication is recommended. They can
be very effective in up to 70 per cent of people who have depression, but like
many medications used to treat medical conditions, it may take a while to find
the right drug for each individual at the correct dose. There are three main
groups of antidepressant medications available on prescription and these are
shown in Table 13.1.
Y our doctor will discuss with you the most suitable antidepressant, taking into
account your past and current medical history, and other medications that
you are taking. All antidepressant medicines should be prescribed by a quali –
fied doctor who has knowledge of the contraindications, interactions, and
potential side effects.

chapter 13 · Depression and coping
151Tricyclics (TCAs)
TCAs have been on the market for over 30 years and have been shown to be
useful to help treat depression and anxiety. They are also used at lower doses
to treat chronic pain.
Selective serotonin reuptake inhibitors (SSRIs)
SSRIs have been on the market for the past 15 years. They are also used in the
treatment of anxiety and some specific disorders such as anorexia, obsessive–
compulsive disorder, and panic attacks. They are becoming increasingly popu –
lar in the management of depression and anxiety.Table 13.1 Types of antidepressant medications
Tricyclics (TCAs) Amitriptyline hydrochloride
Amoxapine
Clomipramine hydrochloride
Dosulepin hydrochloride
Doxepin
Imipramine
Lofepramine
Nortriptyline
Trimipramine
Closely related to tricyclics Maprotiline hydrochloride
Mianserin hydrochloride
Trazodone hydrochloride
Selective serotonin reuptake inhibitors (SSRIs) Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Sertraline
Monoamine oxidase inhibitors (MAOIs)
and reversible inhibitors of monomine oxidase (RIMAs)Isocarboxazid
Phenelzine
Tranylcypromine
Other antidepressant drugs Flupentixol
Mirtazapine
Reboxetine
Tryptophan
Venlafaxine

Osteoarthritis · facts
152Q 1: How soon will it take for them to help my mood?
A: In the majority of people the depression may not improve for about
2–3 weeks although in elderly people this may take up to 6–8 weeks.
Some people can report feeling worse before seeing the benefits and
for this reason it is important for anyone starting an antidepressant to
be regularly reviewed by a clinician or nurse.
Q 2: How long will I have to take them?
A: For those who have not had depression previously, it is recommended
that the medication is continued for approximately 4–6 months follow –
ing an improvement in the symptoms, with a view to preventing future
relapses. For those who have had depression previously or with recur –
rent depression, your doctor may recommend the antidepressants are
taken for a longer period of time. It is important to discuss the likely
duration of treatment with your doctor at the start of your treatment.
Q 3: Do they have side effects?
A: Y es, like many medicines there can be side effects; however, they vary
from drug to drug, and from person to person. Y our doctor should
discuss this with you before starting treatment. It is important to seek
advice should you experience unwanted side effects. Some people # Questions and answers about antidepressantsMonoamine oxidase inhibitors (MAOIs)
MAOIs are an older type of medication. They are effective for all types
of depression but are usually only used in severe cases of depression.
Unfortunately MAOIs carry unwanted side effects and can interact danger –
ously with certain foods; hence they are not so popular now.
Duloxetine
Duloxetine is a member of a new family of antidepressants called ‘dual’ anti –
depressants (for their effects on both serotonin and norepinephrine reup –
take). It was approved by the US medicines regulator FDA (Food and Drug
Administration) for the treatment of chronic pain in osteoarthritis in 2010.
There is increasing evidence on its beneficial effects for the management of
pain in patients with osteoarthritis who do not respond adequately to other
treatments. However, it also has potentially serious side effects, and prescrip –
tion should only be recommended after a careful consideration of risks and
benefits.

chapter 13 · Depression and coping
153find that it takes a trial of more than one tablet before finding the
one that is best suited. Individual side effects of each drug will not be
discussed here so it is important to discuss them with your doctor.
Q 4: Will I become addicted to them?
A: It is not uncommon for people to be reluctant to take recommended
medication for depression due to fears of addiction. Current advice
is that antidepressants are not addictive, but should not be stopped
abruptly. It would be advisable for you to seek medical advice if plan –
ning to stop the medication.
Q 5: What is St John’s wort ( Hypericum perforatum )?
A: This is a herbal remedy that has been popular in recent years for
treating mild-to-moderate depression. However, there are concerns
that it can interact with other medications, therefore it is wise to con –
sult your doctor prior to commencing it. St John’s wort should not be
taken with prescribed antidepressants and although it can be bought
at herbal shops it is important to note that the compositional strength
can vary.
Counselling
Some people may find seeing a non-medical counsellor beneficial, particularly
if there are other reasons as to why emotions such as depression and anxiety
are experienced. As we get older we are more likely to encounter bereave –
ments, or families moving away, resulting in isolation. These are situations
that can contribute to low mood state. Y our GP will be able to recommend a
recognized counsellor in your area.
Cognitive behaviour therapy
If your clinician feels that your levels of anxiety or depression are severe and
highly distressing in your life then they may refer you on to a cognitive behav –
ioural therapist (a psychologist, nurse, or doctor). Cognitive behaviour ther –
apy (CBT) is about changing the way that we think (cognitive) in order to
alter the way that we behave (behaviour), or vice versa. As mentioned earlier,
thoughts and feelings that we have every day affect the way that we behave and
a cycle can start. The aim of CBT is to break this cycle so that we have more
positive thoughts, which then lead to a more useful behaviour. It sounds very
easy on paper, but CBT psychologists and specialist nurses are highly quali –
fied, and spend many years training in this field.

Osteoarthritis · facts
154Relaxation
If we refer back to the physical symptoms of anxiety, it includes muscle ten –
sion which in turn leads to muscle fatigue and increased pain levels. The aim
of relaxation is to therefore break this cycle by relaxing the muscle tension,
enabling the body to recharge itself.
Can everyone do it?
Most people are able to practise relaxation, however there are some people for
whom it may not be recommended, for instance, those who have low blood
pressure or cardiac conditions, those with severe depression, or who have a
history of psychotic hallucinations and delusion. Check with your clinician if
you are in doubt.
Deep breathing (diaphragmatic)
The first thing to think about is your breathing. Breathing is obviously a vital
bodily function and usually we do not notice the action. However, on closer
examination many of us breathe only using the upper part of the lungs rather
than the lower part. Unfortunately pain and feeling anxious can make our
breathing shallower, which can exacerbate stressful feelings. It is therefore
vital to practise deep breathing on a regular basis throughout the day.
How to deep breathe
◆ Sit comfortably in your chair in an upright position.
◆ Put your hands on the area below the ribs and above your abdomen.
◆ Breathe out, then take a longer breath in gently in through the nose.
◆ Y ou should feel the lower part of the lungs fill with air.
◆ Y our abdomen will move under your hand.
◆ Hold the breath for a short moment then breathe out slowly and fully.
◆ The breathing can then be repeated.
Many people are surprised how shallow their breathing has become!
Types of relaxation
There are different forms of relaxation available and they range from quick and
simple to longer, more involved forms. Some techniques are more physical in

chapter 13 · Depression and coping
155their approach (progressive muscle relaxation) and deal with reducing muscle
spasm and tension, others are more psychological and help with our thoughts
(guided imagery).
Progressive muscle relaxation (PMR)
There are two different types of muscle:
1. Involuntary such as the heart or eye muscles which automatically tense
and relaxes.
2. V oluntary such as the calf and shoulders muscles which we can decide to
tense or relax.
The aim of PMR is to help you recognize those voluntary muscles that are
tense and then relax them. As is often the case, we are unaware of muscle ten –
sion until we start to explore it.
◆ Tense the muscle for up to 7 seconds and then relax it for about 25 seconds.
◆ Tense the muscle by approximately 60 per cent (more than this could
cause increased pain)
◆ It is often a good idea to start at the extremities and work your way up
the body relaxing and tensing one voluntary muscle at a time (not all at
the same time!). For instance, start at the feet and work up through the
legs and then the arms and work up to the neck. Following practice many
people discover they can identify when they are tense and then relax the
muscle.
Guided imagery
This type of relaxation is popular with many people. It can be likened to hav –
ing a nice dream. The idea is for you to think of a nice place—at the beach
or in a meadow, for example, wherever you feel at ease—and then for you to
spend some time in that place. Y ou identify smells and sounds and colours.
This guided imagery can take as little or as long as you wish, but it should be
a pleasant experience.
Distraction therapy
Listening to chosen music, reading a good book, and watching a film are all
forms of distraction therapy. They act by diverting our attention away from
the pain or the negative feelings.

Osteoarthritis · facts
156Checklist for successful relaxation
◆ Do your own research into different types of relaxation and then choose the
ones that you feel best suit you. Use tapes and books and CDs to help you.
◆ Choose a range of relaxation styles, for example, one you could use on the
bus that perhaps takes just a few minutes to do or even seconds and then
one that you could do in your coffee break, which may take 10 minutes,
and then one that lasts 30–40 minutes. By having a range of relaxation
techniques you will always have one you can use in different situations.
◆ Relaxation is not easy, keep practising the different techniques and they will
become easier.
◆ Ensure you have a private room where you can do your longer relaxation
and ensure you have a comfortable chair or bed.
◆ Ensure you are not disturbed.
◆ Get into a habit with your relaxation and include it in your everyday
routine.
◆ During the day remember to take regular breaks for relaxation. Try not to
wait until things become stressful before you do your relaxation—try to
pre-empt stress.
Conclusion
Helpful and unhelpful thoughts and feelings play a part in our everyday
lives. For those who have a chronic condition such osteoarthritis, negative
thoughts can become overwhelming, change our behaviour, and inhibit the
way we manage the condition. When assessing each patient good clinicians
will always ask about worries, anxieties, and moods, and offer help where it is
needed. Although nobody wants to have osteoarthritis, life can still have fun
and enjoyment included in it.
It is important to remember that you are not alone in having some of these
negative feelings, and that there are some successful treatments and interven –
tions available today.

15714
Which health
professionals are involved
in OA management ?:
making the most
of your healthcare team
% Key points
◆ A well-rounded healthcare plan requires a well-rounded healthcare
team.
◆ Learning to manage and being involved and educated about the thera –
pies available will greatly enhance the improvements in pain and func –
tion you may obtain.
◆ Allowing others to assist you in managing your condition will greatly
enhance the effect of your own self-management strategies.
A chronic illness affects all aspects of your life—physical, emotional, men –
tal, and even spiritual. So it’s no surprise that managing the effects of your
osteoarthritis means more than taking pills or doing a fitness routine. Living
well with OA includes pain and function control through a variety of means—
everything from exercise, eating well, weight management, taking medication,
to relaxation or surgery. Having a well-rounded healthcare plan requires a
well-rounded healthcare team. What follows is a compilation of some of the
types of healthcare professionals that may be able to assist you in some way
with helping you to manage your OA and its impact in your life. Learning

Osteoarthritis · facts
158to manage and being involved and educated about the therapies available
will greatly enhance the improvements in pain and function you may obtain.
However, central to this idea is that you have to be willing to allow others
to assist you in managing your condition—this is very important. We have
provided more details about those professionals who you are more likely to
interact with in managing OA. As is often the case when compiling lists, one
cannot be comprehensive—there may be other health professionals available
who promote their expertise in managing OA.
You
Any healthcare team or management should have you at the center. The first
step in managing OA symptoms, particularly any chronic pain or stiffness, is
learning as much as you can about what to expect. It’s been shown that the
more you know about it, the better you can manage the disease. This will lead
to less pain, greater ability to do the things that are important to you, and a
better quality of life.
Learn as much as you can about your OA by talking to health profession –
als, calling the Arthritis Information line, researching on the Internet, read –
ing books or other materials, and attending education seminars and self-
management courses. Y ou can gain understanding about the nature of your
condition and what you can do to manage your symptoms as well as to find
further resources about OA treatments. Use caution when using the Internet
for research as not all websites about OA are unbiased or have accurate
information.
Self-management courses
Self-management courses will help you learn and practise techniques for
managing your OA as well as providing support.
These programmes are usually run by health professionals, each specializing
in different fields, as well as people living with OA. In addition to learning how
to deal with pain, you will also find out how to manage your OA more effec –
tively by getting information about:
◆ how to exercise correctly
◆ pain management strategies
◆ safe use of medications and side effects
◆ healthy eating and weight control

chapter 14 · Which health professionals are involved in OA management?
159◆ emotions and arthritis
◆ sleep and managing fatigue
◆ relaxation techniques.
These programmes are run either in small groups, on a one-to-one basis or
may be available as an online course.
The general practitioner (GP)/primary care
physician (PCP)
◆ What they do for you: GPs/PCPs take care of many of your routine medical
needs—conducting an annual physical exam, checking your blood pres –
sure, cholesterol level, and heart rate. They will also monitor the medi –
cines you use and keep track of which specialists you see.
◆ What else you should know: your GP can handle much of your routine med –
ical osteoarthritis-related care, including advice for weight loss, prescrib –
ing of certain medications, treatment of mood disorders, and referral to
allied healthcare professionals. Some GPs even apply injections to relief
pain and improve joint function when needed. They can also refer you
to an appropriate specialist for further evaluation and/or treatment. It is
essential that you have a communicative relationship with your doctor so
that together you can optimize the management of your OA.
The rheumatologist
◆ What they do for you: a rheumatologist is a physician who is qualified by
additional training and experience in the diagnosis and treatment of OA
and other diseases of the joints, muscles, and bones. In addition to treating
OA rheumatologists also treat certain autoimmune diseases, musculoskel –
etal pain disorders, and osteoporosis.
◆ What else you should know: a rheumatologist can provide ongoing care
for your OA or act as a consultant as you continue to work with your
GP/PCP or other specialists. The role the rheumatologist plays in health –
care depends on several factors and needs. Typically the rheumatologist
works with other physicians, sometimes acting as a consultant about a
treatment plan. In other situations, the rheumatologist acts as a manag –
er, relying upon the help of many skilled professionals including clinical

Osteoarthritis · facts
160assistants, nurses, physiotherapists, occupational therapists, psycholo –
gists, and social workers. Teamwork is important, since OA management
is chronic and more often than not one management technique alone
is not sufficient to control your symptoms. Healthcare professionals can
help people with OA and their families cope with the changes this can
cause in their lives.
The orthopaedic surgeon
◆ What they do for you: orthopaedic surgeons evaluate and treat bone, joint,
tendon, and ligament disorders and diseases. Some specialize in particular
types of surgery such as joint replacement or arthroscopy. Another doctor
may refer you to an orthopaedic surgeon to determine if you are a candi –
date for surgery. See Chapter 12 for different surgical options available for
OA and if you may be a candidate.
◆ What else you should know: please recognize that surgery is not the first line
of treatment for OA and should generally only be recommended once other
more conservative modes of treatment have been tried and not helped.
The physiotherapist/physical therapist
A physiotherapist’s aim is to help people resume an active and independent
life both at home and work. They will discuss patients’ treatment with con –
sultants and GPs and keep them fully informed. They will also work closely
with other health professionals such as nurses and occupational therapists.
But essentially, physiotherapists are independent practitioners who are profes –
sionally and legally responsible for their own actions.
Your first appointment
During your first appointment—which could last up to 45 minutes—you will
be asked a number of questions relating to your OA. The physiotherapist will
then examine you in order to find out what causes your particular difficul –
ties. After examining you, the physiotherapist will suggest the treatment most
appropriate for you, which will probably start at the following appointment.
They will also discuss the type, frequency, and likely duration of your treat –
ment. Alternatively, a self-help programme to be carried out at home may
be suggested. To make it easier to examine and treat you properly, you may
be asked to undress down to your underwear. The physiotherapist might also

chapter 14 · Which health professionals are involved in OA management?
161advise you to bring other clothes (such as shorts or jogging pants) on subse –
quent visits.
Treatment
Treatment may take place in a clinic, the hospital ward, the outpatient depart –
ment, a hydrotherapy pool, day hospital, school, your home or workplace.
Depending on your particular needs, any of the following types of treatment
may be used:
◆ Mobilizing, stretching, or strengthening exercises: many people with OA find
that their joints become stiffer than normal. Also, some muscles may
become weak with disuse. Y ou might be shown exercises to improve the
movement in your joints and others to strengthen the supporting muscles.
For example, if you have knee OA the exercises will often focus on your
quadriceps and hamstring muscles.
◆ Hydrotherapy: some people with OA find it is easier to move in water.
Here patients can perform an exercise programme and improve their gen –
eral mobility. Many people find the feeling of warmth and weightlessness
allows them to move with less effort and as a result it relaxes their joints
and muscles. If you have OA involving joints in your lower limbs (espe –
cially knees or hips) this is especially useful.
◆ Electrotherapy: different types of machines are used to speed up the healing
process and relieve pain; some provide gentle heat to the affected joints.
Bear in mind that these passive types of treatment (ultrasound, interferen –
tial) are of limited long-term benefit for your OA.
◆ Cold therapy: when an icepack is placed on a painful joint, it can bring
considerable relief. Icepacks not only increase the circulation and speed
up healing, they also reduce local inflammation and relieve pain.
◆ Relaxation: stress and muscle tension can make OA seem worse. Learning
to release this tension helps a great deal. But there is more to relaxation
than simply putting your feet up. Learning effective relaxation practices
can relieve mental and physical tension as well as improving your general
sense of well-being.
◆ W alking training: this may be particularly important if your problems have
caused you to walk awkwardly, especially if you now need a shoe insert,
assistive device (brace), or a walking aid. The physiotherapist can advise
you on the best kind of footwear and make recommendations if any adap –
tations (like inserts) should be fitted.

Osteoarthritis · facts
162◆ Group sessions: you may also be asked to join exercise sessions with other
people who have similar problems to your own. This is not only valuable
in showing you the exercises to continue at home, but also provides you
with the opportunity to meet and talk with other people who have similar
difficulties.
Whichever treatment is recommended, the physiotherapist’s aim will be to
improve your immediate problems and to provide you with the skills, tech –
niques, and knowledge to help you cope by yourself in the long term. Often
this will include continuing to do exercises at home. If this is recommended
to you, do your best to continue the exercises—the improvements that you
get in muscle strength are reflected in improvements in pain and function.
Importantly these improvements are related to the frequency and intensity
with which you continue to exercise.
Remember, it is your body, so do not be afraid to ask questions at any time
during the course of your examination and treatment—especially if you are
doing something that hurts. Physiotherapists are usually very happy to explain
any aspect of their treatment.
The occupational therapist
◆ Where do I see an occupational therapist? Occupational therapists (or OTs
as they are known) are usually based in hospitals. Y ou will see a hospital-
based OT after you have been given a referral from another doctor such as
a rheumatologist. The OT will usually see you in the occupational therapy
department, on the ward, or in the outpatient clinic—although a home
visit can be made.
◆ How do I prepare for an OT appointment? When you see an OT you will
be asked about any problems you may be having. It may help to write
them down before you go. Think about activities such as washing and
dressing, driving your car, getting around your home, or getting up
from a chair. Be sure also to mention any difficulties you may have
doing your job. Make a note of any questions you want to ask. The OT
will make an assessment of your condition, including which joints are
affected, where there is pain, and so on. Having discovered which activ –
ities are important to you and the particular problems you are experi –
encing, the OT will explore possible solutions with you. If necessary,
this might involve the advice on how best to protect the joints affected
by your OA.

chapter 14 · Which health professionals are involved in OA management?
163An occupational therapist can help by:
◆ Giving practical advice on how you can overcome everyday problems: you may
need to rethink the way you do things and this may involve using spe –
cial equipment. The OT will help you choose which equipment suits your
needs. Some items are easily available, such as a seat raise for your toilet
that makes it easier for you to get up from the seated position. Something
like a motorized scooter, or a bath lift, comes from more specialist sources.
◆ Discussing your condition, how it affects you, and what you can do to help your –
self: if you have OA you need to know how to look after vulnerable joints or
so-called joint protection (reducing the load on joints that are affected). If
you feel tired you can learn to make the most of your energy. Y ou may also
have other practical difficulties (such as climbing stairs, getting in and out
of a car, putting your shoes and socks on, gardening, or in the workplace)
and questions about dealing with your limitations of function on a daily
basis.
◆ T eaching you activities to help improve strength or movement: this may involve
you coming for treatment as an outpatient, and is usually combined with
physiotherapy. The aim is to improve the function of your joints. It may
mean discussing activities you can do to help yourself at home.
◆ T eaching techniques to help you cope with pain: these may be very simple
ideas which you can use at home, for instance, placing a bag of frozen peas
on a painful joint or wrapping a warm towel around a stiff joint. Y ou may
also be taught relaxation methods.
The pharmacist
◆ What they do for you: pharmacists fill prescriptions. They help you avoid
potential drug interactions and suggest strategies to avoid side effects
and improve medication use. They evaluate your medications and answer
questions about them. Pharmacists can also give information about over-
the-counter medications and herbal and dietary supplements.
◆ What else you should know: while you may see several doctors, experts sug –
gest you stick with one pharmacist, who can then keep track of your medi –
cations and provide advice about potential problems. Taking many differ –
ent types of drugs from different pharmacists increases your risk of having
an adverse reaction to one of the drugs or an interaction between drugs.

Osteoarthritis · facts
164The nurse
◆ What they do for you: in addition to taking your blood pressure, draw –
ing blood samples, and providing other routine care, nurses function as
patient educators and advocates. They may talk to you about side effects
of medications, exercise, and diet, and provide appropriate literature on
these topics. Y our nurse may serve as a liaison between you and your doc –
tor: someone who can ‘translate’ a difficult-to-understand diagnosis or
treatment recommendation.
◆ What else you should know: a ‘nurse practitioner’ may be part of your
healthcare team. This is a nurse who has an advanced degree and is quali –
fied to interpret lab tests and prescribe medications for you.
The mental health professional/psychologist
◆ What they do for you: mental health professionals, such as psychologists,
help you cope with the emotional repercussions of chronic illness such as
depression, anxiety, anger, or relationship problems. They may ‘prescribe’
anything from antidepressants to support groups. A mental health profes –
sional typically addresses these issues in one-on-one therapy sessions and
helps you manage pain and stress through relaxation, meditation, hypno –
sis, or biofeedback.
◆ What else you should know: OA can cause chronic pain and this can often
be linked to, and exacerbated by, depression—don’t ignore this possibility,
and please seek help if you are feeling depressed. Most mental health pro –
fessionals can refer patients to a psychiatrist for antidepressants or other
medications, when appropriate.
The exercise therapist
◆ What they do for you: exercise therapists are specialists in the prescription
of exercise, supervising your exercise, and assessing your fitness or suit –
ability for exercise. They often complement the exercises that are given by
a physical therapist, and assist and encourage you to maintain the exercise
programme longer term.
◆ What else should you know: when starting out with exercises please be care –
ful to ensure you don’t injure yourself. Exercises should always be done in

chapter 14 · Which health professionals are involved in OA management?
165a careful and controlled manner. Some mild residual discomfort around
your affected joint during and after exercise is to be expected—more often
than not this simply means that you are working the area.
The nutritionist/dietitian
◆ What they do for you: the nutritionist/dietitian can advise you about getting
adequate nutrition and also managing your weight. For OA it is important
that you are getting adequate vitamin D and also omega 3 fatty acids. In
addition, excess weight can exacerbate your symptoms of OA and only
through weight reduction (preferably through a combination of caloric
restriction and exercise) can you manage this problem and achieve result –
ant improvements in your pain and function.
◆ What else should you know: with your dietitian set realistic targets. Aim for
these and, importantly, maintain them. Changing lifelong habits can be
hard but finding alternatives to eating unhealthy snacks can make an enor –
mous difference.
The podiatrist
◆ What they do for you: podiatrists treat conditions affecting your foot or
ankle, are licensed to perform surgery, and prescribe medication. They
focus on controlling inflammation, preserving joint function, and treating
diseases or abnormalities (bunions, corns, calluses, etc.).
◆ What else you should know: most podiatrists also focus on preventing foot
problems that may occur due to your foot’s shape or abnormalities. In OA
the alignment or posture of your foot can contribute to loading at the knee
or hip. Podiatrists can assist in providing advice about shoewear and if
necessary prescribe orthotics (shoe inserts).
The physiatrist/rehabilitation physician
◆ What they do for you: physical medicine and rehabilitation (PM&R) or
physiatry is a branch of medicine dealing with functional restoration of a
person affected by physical disability. PM&R involves the management of
disorders that alter the function and performance of the patient. Emphasis
is placed on the optimization of function through the combined use of
medications, physical modalities, and experiential training approaches.

Osteoarthritis · facts
166The osteopath
◆ What they do for you: practitioners of osteopathy, called osteopaths (or osteo –
pathic physicians in the USA), have a holistic approach; osteopathic phi –
losophy requires addressing the whole person in diagnosis, prevention, and
treatment of illness, disease, and injury, using manual and physical therapies.
◆ What else you should know: in the USA, physical or manual treatment
carried out by D.O.s (Doctor of Osteopathic Medicine) is referred to as
osteopathic manual medicine or osteopathic manipulative medicine (both
abbreviated OMM). In other countries, manual treatment by osteopaths
is simply referred to as osteopathic treatment, similar to chiropractic,
although the distinction between the two professions remains important
to both.The goal of OMM is the resolution of somatic dysfunction to rees –
tablish the self-regulatory mechanisms of the body. There are various tech –
niques applied to the musculoskeletal system as OMM. These are nor –
mally employed together with dietary, postural, and occupational advice,
as well as counselling to help patients recover from illness and injury, and
to minimize pain and disease. Most osteopaths view manual therapies as a
complement to physiotherapy, and the judicious use of invasive therapies
(pharmaceuticals and surgery) where necessary.
The clergy
◆ What they do for you: a religious leader can assist you with your spiritual
needs. They will pray with or for you, direct you to appropriate religious
texts, and provide spiritual guidance such as counselling or referrals to
other services.
◆ What else you should know: many religious leaders are trained in counselling
and are frequently consulted in lieu of a mental healthcare professional.
The chiropractor
◆ What they do for you: chiropractors help relieve pain and increase your
range of motion through manual manipulation of joints.
◆ What else you should know: chiropractors focus on natural healthcare
treatments, and do not perform surgery or prescribe medicine. They are
trained, however, to diagnose conditions that would require treatment by
a medical doctor—and refer patients to the proper healthcare provider.

chapter 14 · Which health professionals are involved in OA management?
167The acupuncturist
◆ What they do for you: acupuncturists help to relieve pain by inserting small
needles into certain areas of the body. According to research acupuncture
may cause the release of endorphins, or painkilling hormones, and has
been show to be a helpful adjunct to other treatments in managing pain
in OA.
◆ What else you should know: some professional acupuncturists may be
doctors, but most typically are not. Based upon a 2000-year-old system
rooted in Chinese philosophy, it involves inserting fine needles into spe –
cific points in the body, though it is rarely painful. It seems to relieve
pain by diverting or changing the painful sensations which are sent to
the brain from damaged tissues and also by stimulating the body’s own
painkillers (the so-called endorphins and encephalins). This painkilling
effect may only last a short time at the beginning, but repeated treatment
(usually about six or eight weekly sessions) can bring long-term benefit,
often over a period of 6–9 months. If the pain returns, then some more
acupuncture may help for another few months. If after a number of treat –
ments you have not noticed any improvement don’t continue with the
treatment.
As with all treatments to relieve pain (such as physiotherapy and painkill –
ing drugs), breaking the ‘pain cycle’ sometimes gives longstanding relief.
To some extent this depends on the stage of your OA, although acupunc –
ture can help at almost any stage of the illness. As with many conventional
treatments, it cannot cure or reverse the process of OA. Acupuncture may
help someone who cannot tolerate drugs through a painful episode, or it
may be used to manage pain on a long-term basis.
The social worker
◆ What they do for you: social workers help you find practical solutions
required for convalescence or life changes such as relocating, changing
jobs, or caring for an ill parent. For example, if you’re moving, from a
home to an assisted living centre, a social worker can refer you to appro –
priate community resources. If you’re planning for the care of a spouse or
parent, a social worker can also refer you to in-home care services.
◆ What else you should know: social workers also provide counseling services
for people with a chronic illness.

169Signs and symptoms
Mrs Margaret Jones is a 55-year-old lady. She has worked in garden mainte –
nance since the age of 18 years. She enjoys her job, and would not change it
for any other, but in the last few months she has noticed bony outgrowths in
the knuckles of both her hands, and her older sister Jane has told her it might
be osteoarthritis.
It is not the deformity that concerns her the most, actually, but the fact that
on busy days at work, especially when the weather is bad, she has quite an
intense pain in both her hands (the right more than the left). The pain is
worse during the day, and when she gets home in the evening after a day at
work, she can hardly use her hands without pain. Luckily enough, she feels
better after a couple of hours of rest, and the pain does not wake her up in
the night. Only occasionally has she felt some hand stiffness in the morning,
which lasts less than 15–20 minutes. Her right thumb base is where the pain
is worst.
Risk factors and family history
Jane, Mrs Jones’ eldest sister, was diagnosed with hand osteoarthritis when
she was about the same age. She is now 63, and has recently been told she also
has knee osteoarthritis in her left knee, and she seems to remember that their
mum suffered from knee pain in the last years of her life.
Mrs Jones had her menopause at the age of 48, has worked in gardening for
almost 40 years, and she is well aware she should lose some weight: her GP
has told her she is overweight, and her glucose was slightly higher than normal
in a routine blood test taken last year.appendix 1
A typical case history

Osteoarthritis · facts
170Medical opinion
Margaret has finally decided to see her GP, Dr Cox. During the appointment
he told her she had Heberden’s and Bouchard’s nodes (‘typical of wear and
tear arthritis’, he said), and although she had two tender joints in her right
hand, it was mostly her right thumb base that seemed really painful at palpa –
tion and mobilization. None of the joints in her left hand were tender or swol –
len at the time.
Dr Cox thinks she has hand osteoarthritis, but to rule out other conditions he
would like her to have a blood test and a plain radiograph of her both hands.
In the subsequent appointment, Dr Cox goes through the results of the
tests with Mrs Jones: her blood test is completely normal, except for a slight
increase in her fasting glucose levels (a different matter), and some radiologi –
cal signs of osteoarthritis. Interestingly enough, it is not only her right hand
that seems to have some radiographical OA, but also her left hand, and in fact,
the radiographic signs look more severe in the left than the right hand. No
images of erosions were noticeable though.
Having seen all this, Dr Cox confirms his original impression: Mrs Jones has
hand osteoarthritis.
Treatment
Dr Cox gives Mrs Jones some general advice:
1. She should do some physical exercise and diet in order to lose some
weight. Although the association between overweight and hand osteoar –
thritis is weaker than with other joints, she is at risk of having knee osteo –
arthritis when she gets older, and losing weight will help her minimize that
risk. Moreover, Dr Cox is concerned about her raised glucose blood levels
(‘in the range of pre-diabetes’, he says), and he thinks losing about 5 per
cent of her current weight (about 7 pounds/3 kilograms) will delay the
onset of a threatening type 2 diabetes.
2. Dr Cox also recommends she should look at some websites. A number of
local charities can offer lots of useful information on strategies for self-
management and reducing pain in osteoarthritis. She should definitely
join one of these organizations.
3. In terms of medications, Dr Cox has only prescribed paracetamol tablets
(paracetamol 1g three times a day when she is in pain) and a diclofenac gel
on a regular basis.

appendix 1 · A typical case history
1714. Margaret has read somewhere that there are a number of supplements
that can help to treat osteoarthritis. Dr Cox explains there are different
food supplements she can purchase over the counter in pharmacies and
specialized shops, but it her responsibility to read about the potential risks
and benefits of these and decide whether she wants to take any of them.
Prognosis: 10 years later . . .
Mrs Jones was told that not all patients with osteoarthritis progress and get
worse. However, she took the problem seriously, and lost quite a bit of weight
(almost 1 stone/6 kilograms in the year after she was diagnosed). Her hands
are still painful when things get busy at work, but she copes well with par –
acetamol and NSAID tablets, together with some diclofenac gel, which she
applies almost daily in winter. She is now close to retiring, and usually spends
longer hours in her office than working outside. The good news is she has no
knee pain, and although her sister Jane suggests she should have a knee X-ray,
she is not keen, as she does not have any symptoms.
A different matter is Jane. Despite being sisters, Jane and Margaret are very
different. Jane was in charge of caring for Margaret and their youngest brother
Adam at a young age, when their mum passed away. She was diagnosed with
hand osteoarthritis when she was 57, and only a few years later was told that
she also had knee OA. Although her hands look very deformed, it is her knees
that are most painful. She was referred to rheumatology clinics where she has
had injections in her right knee twice in the last year. Although these seemed
to help reduce the pain for a few weeks, she is now considering having a knee
replacement.

173Patient information (registration is not necessary)
◆ My Joint Pain
<http://www.myjointpain.org.au>.
◆ National Institute of Arthritis and Musculoskeletal and Skin Diseases
<http://www.niams.nih.gov>.
◆ Arthritis Research Campaign (UK)
<http://www.arc.org.uk>.
◆ Arthritis Foundation (USA)
<http://www.arthritis.org>.
◆ American College of Rheumatology
<http://www.rheumatology.org>.
◆ Johns Hopkins Arthritis Centre
<http://www.hopkins-arthritis.som.jhmi.edu/rheumatoid/rheum.html>.
Depression and coping
For more information see:
◆ Beyond blue
<http://www.beyondblue.org.au/>.appendix 2
Useful addresses

Osteoarthritis · facts
174◆ My Joint Pain
<https://myjointpain.org.au/>.
Support groups
Arthritis Care (UK)
Arthritis Care is the UK’s largest organization working with all people who
have arthritis to provide information and support. They are a user-led organi –
zation meaning that people with arthritis are integrally involved in all of their
activities.
Tel: 0808–800–4050.
Website: <http://www.arthritiscare.org.uk>.
Arthritis Foundation (USA)
The Arthritis Foundation in the USA is the only national not-for-profit organ –
ization that supports the more than 100 types of arthritis and related condi –
tions with advocacy, programmes, services, and research. General queries for
arthritis-related information and materials:
Tel: 404–872–7100 or 1–800–568–4045.
Website: <http://www.arthritis.org>.
Devices and other therapies
◆ My Joint Pain
<https://myjointpain.org.au/treatments/devices-and-other-therapies/>.
Diet and osteoarthritis
◆ My Joint Pain
<http://www.myjointpain.org.au/treatments/nutrition/>.
<http://www.myjointpain.org.au/factsheets/healthy-eating-and-arthritis/>.
◆ Arthritis Foundation
<http://www.arthritistoday.org/what-you-can-do/eating-well/>.

appendix 2 · Useful addresses
175◆ Arthritis Research UK
<http://www.arthritisresearchuk.org/arthritis-information/arthritis-and-
daily-life/diet-and-arthritis.aspx>.
Health eating
◆ Australian Dietary Guidelines
<http://www.eatforhealth.gov.au>.
Exercise
◆ Arthritis Australia, Exercise
<https://myjointpain.org.au/treatments/exercise/>.
◆ American College of Rheumatology, Exercise and Arthritis <http://www.
rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/
Exercise_and_Arthritis/>.
◆ National Institute of Arthritis and Musculoskeletal and Skin Diseases,
Handout on Health: Osteoarthritis
<http://www.niams.nih.gov/Health_Info/Osteoarthritis/default.
asp#box_5>.
◆ Mayo Clinic, Exercise helps ease arthritis pain and stiffness
<http://www.mayoclinic.com/health/arthritis/AR00009>.
◆ NHS, Get running with Couch to 5K
<http://www.nhs.uk/Livewell/c25k/Pages/get-running-with-couch-to-5k.
aspx>.
Tai Chi
For more information about Tai Chi see <http://www.taichiproductions.com>
and the publication Overcoming Arthritis (Dorling Kindersley Publishers
2002) by Dr Paul Lam and Judith Horstman, which contains 160 photos with
detailed instructions and information about Tai Chi and arthritis.

Osteoarthritis · facts
176Yoga
For more information about yoga, see the website of the International
Association of Y oga Therapists <http://www.iayt.org> and for some poses see
<http://www.abc-of-yoga.com/yoga-and-health/yoga-for-arthritis.asp>.

177Abduction of a joint means to move it away from the midline of the body, e.g.
standing straight and lifting one foot off the ground and moving it outwards.
Acetabular dysplasia the cup-like shape of the hip bone is slightly abnormal
in shape so as not to securely support the femur and often necessitates surgery.
Acupuncture this originated in China over 2000 years ago and is based on
the foundation that good health relies on an equal balance of forces that then
ensure a good body flow of energy— chi or qi. It believes that ill health is the
response to an imbalance of these forces. Acupuncture needles are inserted
over certain pathways with the aim of stimulating the brain to release chemi –
cals that can improve general well-being and promote healing. In more recent
times the Western world has developed acupuncture using a more biological
approach to promote general well-being.
Ambulatory devices are aids that can help you with walking such as crutch –
es, walking sticks, and frames.
Ambulatory pain pain experienced when walking.
Analgesia means pain relief.
Analgesics this is the name given to drugs that relieve pain, e.g. paracetamol,
NSAIDs, mild opioids, strong opioids.
Aromatherapy this is the use of plant extracts to help health and well-being.
It is used in the form of massage oils, inhaled, or used in baths.
Arthrocentesis the puncture and aspiration of a joint.
Arthrodesis a form of surgery that fuses joints together and in so doing immo –
bilizes the joint.Glossary

Osteoarthritis · facts
178Arthroplasty a form of surgery that changes the joint, for instance, a joint
replacement.
Arthroscopic debridement a form of surgery that involves inserting a nar –
row tube into the joint through which instruments are passed to enable the
surgeon to take out flaky pieces of cartilage, or loose pieces of bone.
Arthroscopy a form of surgery that involves inserting a narrowing tube into
the joint through which the surgeon can conduct an examination (and also
perform some surgical procedures).
Articular capsule is the name given to two layers of connective tissue that
surround the structures of the joint.
Body mass index ( also called the BMI ) is the standard scientific table used
in medicine to ascertain the desirable weight we should strive to maintain for
good health. It is calculated by dividing the weight in kg by the height in m2.
We should be aiming for 20–25.
Bouchard’s nodes these are the bony nodules found on the proximal phalan –
geal joint (joint between the knuckle and small joint at the end of each finger).
Capital femoral epiphysis slipped capital femoral epiphysis (SCFE) is a hip
problem that starts if the epiphysis (growing end) of the femur (thigh bone)
slips from the ball of the hip joint.
Cartilage is found at the end of the bones and stops the bones rubbing
together and also acts as a shock absorber.
Chondrocytes cells that make cartilage.
Chondroitin a naturally occurring substance found in the cartilage that is
part of the protein that gives cartilage its elasticity.
Collagen fibres found within the cartilage that give it its structure and
strength.
Complementary therapies the umbrella name given to a host of therapies
that are not considered part of conventional medicine, e.g. acupuncture, aro –
matherapy, reflexology, herbal medicine, and homeopathy.
Congenital a condition you are born with.
Contralateral the opposite side.

Glossary
179Corticosteroids these are hormones that are either produced naturally or
synthetically. They have various metabolic functions and are able to reduce
inflammation.
Crepitus a crunching felt on moving the joint.
Cruciate ligaments the ligaments found in the knee joint.
Cysts an abnormal sac in the bone near the joint containing a liquid substance.
Degenerative joint disease is another term for OA, it means the deteriora –
tion of the joint over time.
Distal farthest away, for instance, the distal phalangeal joint is the finger joint
farthest from the body.
Effusion fluid within the joint.
Endochondral ossification the formation of bone tissue within cartilage;
the process by which bones grow in length. Local risk factors of osteoarthritis
are factors that are specific to a joint such as meniscal damage in the knee or
muscle weakness around the joint.
Endorphins naturally occurring chemicals in the body that create analgesia
and a sense of well-being.
Erythrocyte sedimentation rate a blood test that establishes inflammation
within the body.
Essential fatty acids (EFAs) these are fats that the body cannot produce
for itself, they are obtained by eating foods that contain them. The body uses
them to make chemicals (prostaglandins and leukotrienes) that can reduce the
breakdown of cartilage and reduce inflammation.
Gait is the term given to one’s natural walking technique; some clinicians may
describe it as unsteady (as risk of falling) or wide (steps are taken in a wide
fashion).
Glucosamine naturally occurring component of the cartilage, also found in
shellfish and synthetically manufactured. It is now widely used in the field of
OA as it can reduce pain and also help remodel cartilage.
Gout a form of arthritis associated with an excess of uric acid in the body.
Heberden’s nodes nodes found on the distal phalangeal joint in severe hand OA.

Osteoarthritis · facts
180Homeopathy a 200-year-old form of medicine based in treating like on like to
cure (for instance, if you wish to be cured of your sickness then the treatment
would be to cause the sickness). Small quantities of a substance are diluted
down so that only a few molecules are present and then they are administered.
Hyaline cartilage the cartilage that is affected in osteoarthritis, it is found in
most moving joints.
Hyaluronic acid a naturally occurring component of the synovial fluid and
found in the cartilage. In OA there is a depletion of this and hence an intra-
articular injection of hyaluronic acid may be indicated.
Hydrotherapy a form of physiotherapy that is conducted in water.
Intra-articular injections injections that are passed directly into the joint.
Lateral on the outside.
Ligaments these are strong fibrous tissues that connect bone to bone and in
so doing play a role in keeping the joint secure and stable.
Local risk factors of osteoarthritis are factors that are specific to osteo-
arthritis.
Medial on the inside.
Menisci these are found within the knee joint and are little spacers, that is,
they help pad out the knee joint to prevent structures collapsing on each other.
Some people refer to these as cartilage but that is not strictly correct.
Micronutrients necessary chemicals often in minute amounts that are
required by our body for normal growth and development.
Mild opioids these are the milder forms of opioids and are chemical sub –
stances that have a morphine-like action in the body.
Mitochondria a structure in the cytoplasm of all cells except bacteria in
which food molecules (sugars, fatty acids, and amino acids) are broken down
in the presence of oxygen and converted to energy.
Neutraceutical a food or naturally occurring food supplement thought to
have a beneficial effect on human health.
NSAID non-steroidal anti-inflammatory drug.

Glossary
181Opioid an opioid is a chemical substance that has a morphine-like action in
the body.
Osteopathy osteopathy is a non-invasive manual medicine that focuses on
total body health by treating and strengthening the musculoskeletal frame –
work, which includes the joints, muscles, and spine.
Osteophytes osteophytes are bone and cartilage that forms in a joint with
osteoarthritis. Osteophytes can develop as marginal (on the periphery of
joints) or central (mostly in the knee and hip).
Osteoarthritis (OA) OA is not a single disease but rather the end result
of a variety of disorders leading to the structural or functional failure of one
or more of your joints. Osteoarthritis involves the entire joint including the
nearby muscles, underlying bone, ligaments, joint lining (synovium), and the
joint cover (capsule).
Osteotomy osteotomy (‘bone cutting’) is a procedure in which a surgeon
removes a wedge of bone near a damaged joint. This shifts weight from an area
which is damaged to an area where there is a healthier joint surface.
Oxidant a substance that oxidizes another substance.
Oxidative damage in the natural process of oxidation (turning oxygen into
needed energy), our bodies produce toxins called ‘free radicals’. These mol –
ecules can cause damage to cells and DNA, but are generally ‘mopped up’ by
substances called antioxidants before they can hurt us.
Pathological relating to or caused by disease.
Perioperative relating to, occurring in, or being the period around the time
of a surgical operation.
Polyunsaturates an unsaturated fat is a fat or fatty acid in which there are
one or more double bonds in the fatty acid chain. A fat molecule is monoun –
saturated if it contains one double bond, and polyunsaturated if it contains
more than one double bond.
Proximal nearer to a point of reference such as an origin, a point of attach –
ment, or the midline of the body.
Reflexology a system of massaging specific areas of the foot or sometimes the
hand in order to promote healing, relieve stress, etc. in other parts of the body.

Osteoarthritis · facts
182Sclerosis a thickening or hardening of a body part, such as bone in the joint
of someone with OA, especially from excessive formation of fibrous interstitial
tissue.
Sciatica pain along the sciatic nerve usually caused by a herniated disc of the
lumbar region of the spine and radiating to the buttocks and to the back of
the thigh.
Septic arthritis infective arthritis may represent a direct invasion of joint
space by various microorganisms, including bacteria, viruses, mycobacteria,
and fungi.
Synovial capsule a closed sac of synovial membrane situated between the
articular surfaces of joints.
Synovial fluid a clear fluid secreted by membranes in joint cavities, tendon
sheaths, and bursae, and functioning as a lubricant.
Synovial joint a joint so articulated as to move freely.
Synovium a thin membrane in synovial (freely moving) joints that lines the
joint capsule and secretes synovial fluid.
T’ai chi an ancient Chinese martial art form that was developed to enhance
both physical and emotional well-being.
Tendons a tendon is a tough yet flexible band of fibrous tissue. The tendon is
the structure in your body that connects the muscle to the bones.
Transcutaneous nerve stimulation (TENS) involves the passage of low-
voltage electrical current to electrodes pasted on the skin.
Valgus abnormal angulation of a bone or joint, with the angle pointing
towards the midline.
Varus abnormal angulation of a bone or joint, with the angle pointing away
from the midline.
Y oga a system of exercises to promote control of the body and mind.

183A
acetabular dysplasia 17
acetaminophen (paracetamol) 55, 103,
104, 105
acromioclavicular (AC) joint 27
acupuncture 72, 95–6, 96f, 167
acute illness versus chronic conditions 5
adrenaline 148
aerobic exercises 67–9, 69t
age, and OA 13–4, 41
alcohol 89
alternative therapies see complementary
therapies
ambulatory assist devices 120, 121f
American College of Rheumatology
(ACR) 34, 52
hand OA diagnostic criteria 36
knee OA diagnostic criteria 34–5
amitriptyline 56, 108–9
anaemia 89
anaesthesia 135
analgesics 46, 47, 55, 56, 103–4, 103f
ladder model 103, 103f
non-opioid drugs 103, 103f
opioid drugs 56, 103–4, 103f, 104
over-the-counter 55
starting medication 104
see also non-steroidal anti-inflammatory
drugs (NSAIDs)
anger 145
ankles 5, 129, 138, 165anterior cruciate ligament (ACL)
injuries 16, 59–60
antidepressants 150–3
addiction, possibility of 153
duration of treatment with 152
effect, speed of 152
monoamine oxidase inhibitors
(MAOIs) 151t, 152
questions and answers 152–3
selective serotonin reuptake inhibitors
(SSRIs) 151, 151t
side effects of 152–3
St John's wort 153
tricyclics (TCAs) 151, 151t
types of 151t
antioxidants 15, 86
anxiety 145, 147–9
effects on osteoarthritis 149f
explanation of 147–8
physical effects of 148f, 149
signs and symptoms of 148
treatment of 149–56
aquatic exercise 66–7, 70
aromatherapy 96–7
Arthritis and Rheumatism Council 62
Arthritis, Diet, and Activity Promotion
trial 54–5
Arthritis Research Campaign 150
arthritis, types of 3
arthrocentesis 34
arthrodesis/joint fusion 138, 138fIndex
Note: The suffix ‘f’ following a page number indicates a figure and ‘t’ indicates a table. ‘OA’
is the abbreviation for osteoarthritis.

184Osteoarthritis · facts
arthroplasty/joint replacement 56, 129–34
complications 130–1
contraindications 133
kneecap replacement 132–3, 132f
patient selection for 133–4
preoperative visit 134
recovery from 130
surgical procedure 129–30
total joint replacement 132
total knee replacement 129, 132f
unicompartmental replacement 132, 132f
arthroscopic debridement 56, 137
arthroscopy 34
Arthrotec® 105, 107
aspirin 87, 89, 105, 116
asymptomatic radiographic OA 32
autologous chondrocyte therapy/
implantation (ACT/ACI) 139, 140, 140f
avocado 117
B
back 5
Baker's cyst 25, 25f
balneotherapy see aquatic exercise
behaviours 144, 145
body mass 30
body mass index (BMI) 15, 82
bone angulation 7f
bone density, and osteoarthritis 14–5
bone metabolism 12f, 15, 87
bone spurs see osteophytes
bone tissue 6, 45
bony enlargement 23
Bouchard's nodes 23, 26f, 27, 31, 36, 45
bow legs (genu varum) 17, 30, 31f, 43, 44f
braces
hands 125, 125f
knees 58, 58f, 121, 122–3, 123f, 124f
breathing exercises 134, 154
broccoli 16
bunions 27
C
calcium 88–9
'cam impingement' 45, 46f
canes 55, 120, 121f
capsaicin 56, 109
cardiovascular disease 21
cartilage 4, 5, 6, 57f
grafting 139–41hyaline articular cartilage in 4
hyaluronic acid 112
loss of 32, 37
nutrition and 15–6
osteoporosis and 15
repair of 13
rheumatoid arthritis and 8
role of 6
transplantation 139–41
vitamin C and 116
vitamin D and 15, 116
vitamin K and 87
celecoxib 107–8
chiropractors 166
chondrocytes 114
chondroitin 114, 118
chondroitin sulphate 53, 56, 60, 101, 115–6
chronic conditions versus acute illness 5
clergy 166
clinical examinations 30, 31
clodronate 110
cognitive behaviour therapy (CBT) 153
cold treatments 119, 120f, 161
complementary therapies 91–100
acupuncture 72, 95–6, 96f, 167
aromatherapy 96–7
choosing 93–4
and conventional medicine 94–5
copper bangles 97, 97f
description of 91–2
dietary supplements 97–8
see also supplements
herbal medicine 98–9
homeopathy 99
lifestyle changes 95
magnetic therapy 99
massage 72, 99–100
medical advances 92
osteopathy 100, 166
reflexology 100
self-healing 95
symptom control 93
therapists, qualifications of 93
unregulated 94
copper bangles 97, 97f
coral calcium 97
coronary heart disease 12–3
corticosteroid intra-articular injections 56,
111–2, 117
counselling 153

185Index
Cox-2 inhibitors, selective 107–8
crepitus 23, 29
crutches 121f
cysts 27, 32
D
'decaying cartilage' 8
'degenerative arthritis' 8
'degenerative changes' 8
degenerative disc disease 25
‘degenerative joint disease’ 8
denial 145
depression 143–56
and anxiety 145
effects on osteoarthritis 147, 147f
signs and symptoms of 146
treatment of 149–56
unipolar versus bipolar 145
device use
ambulatory assist devices 120, 121f
hand braces 125, 125f
heat and cold 119, 120f
knee braces 58, 58f, 121, 122–3, 123f,
124f
patella taping 124f, 125
transcutaneous electrical nerve
stimulation (TENS) 120
diabetes 52, 112
diacerein 60
diagnosis, of OA 29–38
arthroscopy 34
criteria 34–7
hip OA 37
knee OA, ACR 1991 diagnostic
criteria 34–6
laboratory tests 33–4
magnetic resonance imaging (MRI)
scan 34
medical history 29–30
physical examination 30–1
risk factors 30
symptoms 29
X-rays 31–2, 33f
diclofenac 89, 105
diet 54–5
balanced 80–1, 80f
calcium 88–9
essential fatty acids 85–7
iron 89
OA risk factors 15–6and weight loss 79–89
see also supplements; vitamins;
weight control
dietitians 165
diflunisal 105
distal interphalangeal joint (DIP) 26, 36,
44f, 45
distraction therapy 155
doxycycline 60
duloxetine 56, 108, 109, 152
E
education 54, 150
effusion 23
elbows 5
electrocardiograph (ECG) 134
electrotherapy 161
emotions 143, 144, 144f, 145
endurance exercises 67–9, 72
erosive hand OA 110
erythrocyte sedimentation rate (ESR) 33
essential fatty acids 85–7
essential oils 96–7
ethnic groups, and OA 15
etoricoxib 107–8
European league against Rheumatism
(EULAR) guidelines 34, 52
hand OA 36–7
knee OA 35–6
exercise 54–5, 65–77, 161
benefits of 65–6, 73
endurance exercises 67–9, 72
excessive 72
frequency of 72
group sessions 162
pain relief during 71–2
t'ai chi 75–7
and weight control 84–5
yoga 74–5
exercise programme guidelines 66–70
activity, appropriacy of 71
aerobic exercises 67–9, 69t
aquatic exercise 66–7
beginning slowly 71
joint protection strategies 71
knee OA 68f
maintaining 73–4
range-of-motion (ROM) exercises 66
recommended physical activity for adults
with OA 69t

186Osteoarthritis · facts
exercise programme guidelines ( continued )
recreational/lifestyle activities 69–70
starting exercise 70–1
strengthening exercises 67
exercise therapists 164–5
F
facet joints 47
fats
eating less 83–4
essential fatty acids 85–7
monosaturated 83
polyunsaturated 83
saturated 83
feelings 143, 144
feet 27
footwear, supportive 55
feet OA
pain 24f
progression of 47
symptoms 27
femoroacetabular impingement 18
fenbufen 105
FIFA (Fédération Internationale de
Football Association) 16, 60
finger OA 24f, 26–7, 45–6
fish liver oil 85–6
supplements 86–7
fitness levels 13–4
footwear, supportive 55
see also orthotics
frames 120, 121f
free radicals 15, 86
fruit and vegetables 83, 84
G
Garrod, A.E. 4
'gelling' 22
gender, and OA 14
general practitioners (GPs) 159
genetics, and OA 14
genu valgum (knock knees) 30, 31f, 43, 44f
genu varum (bow legs) 17, 30, 31f, 43, 44f
ginger 117
glenohumeral (shoulder) joint 27
glucosamine 114–5, 118
glucosamine hydrochloride 114, 115
glucosamine sulphate 55, 60, 101, 114–5
gout 4, 34, 89
green-lipped mussel extract 97–8growth hormones 13
guided imagery 155
H
hand OA 14, 15, 17, 31
diagnosis of 36–7
erosive hand OA 110
joint involvement in 44f
nodular swelling of the DIP and PIP
joints 37f
obesity and 18
progression of 45–6
symptoms 26–7
hands 5, 31, 44f
braces 125, 125f
hatha yoga 74
healthcare professionals 157–67
heat treatments 119, 120f
Heberden's nodes 4, 14, 23, 26, 26f, 31,
36, 41, 45
Heberden, William 4
heel wedges 121, 122f
hemiarthroplasty 132
heparin 116
herbal medicine 98–9
hip OA 14, 15, 17
clinical examination 30
diagnosis of 37
joint deformity/shape and 17–8
obesity and 18
pain 22, 24f
physical examination (signs) 31
progression of 45
range-of-motion (ROM) exercises for 66
symptoms 27
hips 5
hip replacement see arthroplasty/joint
replacement
slipped capital femoral epiphysis 17
homeopathy 99
hormone replacement therapy 14
hospital stays 134–6
admission to 134
anaesthesia 135
discharge 135–6
follow-up appointments 136
mobility, regaining 135
operation 135
post-operative recovery 135, 136
preoperative visit 134

187Index
Hunter, William 4
hyaline articular cartilage 4
hyaluronans 56
hyaluronic acid 112–3, 117, 118
hydrotherapy 66, 72, 161
hydroxychloroquine 110
I
ibuprofen 89, 105
incentive spirometry 134
indometacin 105
information, obtaining 54
support groups 174–6
websites 173–6
injection therapies 101, 110–3
corticosteroid intra-articular
injections 56, 111–2, 117
hyaluronic acid injections 117
intra-articular injections 56, 110, 111–3,
117, 118
injuries
acute 16
joint 13, 16, 42, 59–60
and OA 16
insoles, wedged 121, 122f
Internet 150, 158
IOC (International Olympic
Committee) 16, 60
iron 89
J
joint injury 13, 16, 42, 59–60
and progression of OA 42
risk factors 13
joint protection strategies 163
joint replacement see arthroplasty/joint
replacement
joints
affected by OA 5
deformity/shape of 17–8
enlargement 29
loading, repeated 17
locking 30
with mild OA 6, 7f
modifying underlying structure
of 53
movement limitation 29–30
with osteoarthritis 5–6
pain, asymmetric 29
with severe OA 7–8, 7fsee also synovial joints
joint stiffness 29
K
ketoprofen 105
ketorolac 105
knee alignment 30
knee arthroscopy, incision sites 138f
knee braces 58, 58f, 121, 122–3, 123f, 124f
kneecap replacement 132–3
knee OA 15, 16, 17, 55, 117
acupuncture for pain relief in 96
arthroscopic debridement 137
clinical examination 30
diagnosis of 30–1, 34–6
duloxetine and 108, 109
exercises 68f
glucosamine and 115
obesity and 18, 82
pain 24f
patient perspective 61–3
physical examination 30–1
prevalence of 43f
prevention of 16
progression of 41, 42–5, 43f
quadriceps strength and 17
range-of-motion (ROM) exercises for 66
risk factors 13
strontium ranelate and 110
supportive footwear for 55
symptoms of 25
and vitamin D 16
weight loss and exercise 81
knees 5
arthroscopic treatment 137, 138f
Baker's cyst 25, 25f
corticosteroid injections 111–2
mechanical forces 57, 57f
meniscus 137
osteotomy/realignment 137–8, 139f
knee taping 125
knock knees (genu valgum) 30, 31f, 43, 44f
knuckles (metacarpophalangeal joints)
36, 44f
L
laboratory tests 33–4
erythrocyte sedimentation rate (ESR) 33
rheumatoid factor 34
synovial fluid analysis 34

188Osteoarthritis · facts
ligaments 6
lumaricoxib 107–8
lumbar radiculitis (sciatica) 31
M
magnetic resonance imaging (MRI) scan 34
magnetic therapy 99
management, of OA 51–63
algorithm for 54f
disease process, altering 60
education 54
exercise 55
future treatments 56–9
joint injury 59–60
non-pharmacological approach 54–5
obesity and 59
patient perspective 61–3
published guidelines 52
risk factors, modifying 53
supportive footwear 55
surgery 56
weight loss 54–5
see also treatments
manipulation 72
massage 72, 99–100
mechanical forces 57, 57f
medical history 29–30
medications 53, 101
common medicines 104–10
forms of 102
pain-relieving (analgesics) 103–4
selective Cox-2 inhibitors 107–8
strontium ranelate 109–10
taking regularly 102–3
unlicensed 102
see also analgesics
meloxicam 105
meniscus 6f, 13, 32, 137
mental health professionals 164
metacarpophalangeal (MCP) (knuckle)
joints 36, 44f
microfractures 141
mild osteoarthritis 6, 7f
Mini Mental Status Exam (MMSE) 134
mobilization therapies 72
monoamine oxidase inhibitors
(MAOIs) 151t, 152
morning joint stiffness 29
mosaicplasty 139, 140
muscles 6involuntary 155
quadriceps 55
strength 13–4, 17
strengthening exercise programme 69t
voluntary 155
weakness 23–4, 42
musculo-skeletal system 17, 42, 166
see also joints
N
nabumetone 105
naproxen 105
neck 26
nerves 22, 26, 72, 108, 109
neuromuscular conditioning
programmes 16, 60
New Zealand green-lipped mussels 98f
non-opioid drugs 103
non-steroidal anti-inflammatory drugs
(NSAIDs) 46, 47, 56, 62, 87, 89, 103,
105–7
creams/gels 107
side effects of 106–7
see also analgesics
norepinephrine 148
nurse practitioners 164
nurses 164
nutrition 15–6
see also diet
nutritionists 165
O
obesity 13, 41–2, 59
arthroplasty/joint replacement and 134
and knee OA 82
and progression of OA 41–2
risk factors 13, 18
occupational therapists (OTs) 162–3
occupation, and osteoarthritis 17
oestrogen 14
omega-3 fatty acids 81, 85
omega-6 fatty acids 85, 86
opioid analgesics 56
strong opioid drugs 104
weak opioid drugs 103–4
orthopaedic surgeons 160
orthotics 58, 71, 121
osteoarthritis
as a chronic disease 5
definition of 4

189Index
history of 3–4
individual experiences of 9
joints affected by 5
joints with 5–6
meaning of 4
other names for 8
prevalence of 8
Osteoarthritis Research Society
International (OARSI) 52, 150
'osteoarthrosis' 4, 8
osteonecrosis 45
Osteopathic Manual/Manipulative Medicine
(OMM) 166
osteopaths 166
osteopathy 100, 166
osteophytes 6, 23, 26, 32, 33f, 37
osteoporosis (brittle bones) 8, 14–5,
109
osteotomy/realignment 56, 137–8, 139f
outlook see progression, of OA
oxidants 114
P
pain 5, 22, 29
common sites 24f
hip osteoarthritis 22
referred pain 31
pain-management programmes 150
pain relief
chondroitin 101
during exercise 71–2
see also analgesics; non-steroidal
anti-inflammatory drugs
(NSAIDs)
paracetamol 55, 103, 104, 105
patella taping 124f, 125
patellofemoral joint arthroplasty 133
patellofemoral replacement 133
pharmacists 163
pharmacological therapies 55–6
analgesics 55, 56
intra-articular injections 56
supplements 55–6
vitamins 55–6
physiatrists 165
physical activity, and osteoarthritis 17
physical examinations 30–1
physical medicine and rehabilitation
(PM&R) 165
physical therapists see physiotherapistsphysiotherapists 160–2
first appointment 160–1
treatments 161–2
piroxicam 105
placebo effect 79
podiatrists 165
pool therapy see aquatic exercise
postural alignment 30
primary care physicians (PCPs) 159
prognosis see progression, of OA
progression, of OA 40
age 41
feet OA 47
general factors affecting 40–2
hand OA 45–6
hip OA 45
knee OA 42–5
multiple joints and 41
obesity and 41–2
research and 40
shoulder OA 46–7
specific joints 42–7
spine OA 47
progressive muscle relaxation (PMR) 155
prostaglandins 106
prostheses 129, 130f, 131
proximal interphalangeal joint (PIP) 27, 45
'pseudo-tumour' 131
psychologists 164
Q
quadriceps 17, 55
R
radio-opaque thickening 32
range-of-motion (ROM) exercises 66, 72
recreational/lifestyle activities 69–70
referred pain 31
reflexology 100
regenerative medicine 58
rehabilitation physicians 165
relaxation therapy 72, 154–6, 161
checklist for successful 156
deep breathing 154
distraction therapy 155
guided imagery 155
progressive muscle relaxation
(PMR) 155
types of 154–5
religious leaders 166

190Osteoarthritis · facts
reversible inhibitors of monoamine oxidase
(RIMAs) 151t
rheumatoid arthritis 8
rheumatoid factor 34
rheumatologists 159–60
risk factors 12, 12f, 30
age 13–4
family history 11, 12, 32
knee osteoarthritis 13
lifestyles 11
local 12, 16–8
medical history 29–30
modifying 53
multifactorial 12
nutrition 15–6
systemic/general 12, 13–6
see also obesity
rofecoxib (Vioxx®) 108
S
S-adenosylmethionine (SAM-e) 117
sciatica (lumbar radiculitis) 31
sclerosis 32, 33f, 40, 45
selective Cox-2 inhibitors 107–8
selective serotonin reuptake inhibitors
(SSRIs) 151, 151t
self-management courses 158–9
septic arthritis 111
serotonin see selective serotonin reuptake
inhibitors (SSRIs)
severe osteoarthritis 7–8, 7f
shoe inserts see orthotics
shoulder joint 27
shoulder OA
progression of OA 46–7
symptoms 27
shoulders 5
signs see symptoms and signs
smoking, preoperative cessation of 134
social workers 167
soya beans 117
spine OA
pain 24f
progression of 47
symptoms 25–6
sport injuries 16, 59–60
sports 13, 17, 70
spurs see osteophytes
SSRIs see selective serotonin reuptake
inhibitors (SSRIs)standing, postural alignment 30
stiffness 5, 22–3
St John's wort 153
strengthening exercises 67, 72
strontium ranelate 53, 109–10
sugar 84
sulforaphane 16
sulindac 105
supplements 55–6, 97–8, 113–7, 118
antioxidants 86
chondroitin sulphate 101
coral calcium 97
glucosamine 114–5
green-lipped mussel extract 97–8
see also vitamins
support groups 174
supportive footwear 30
surgery 56, 127–41
anaesthesia 135
arthrodesis/fusion 138
arthroplasty/joint replacement 129–34
arthroscopic debridement 137
arthroscopic treatment 137
benefits of 128
cartilage grafting/transplantation 139–41
follow-up appointments 136
going home after 135–6
hospital stays 134–5
length of operation 135
mobility after 135
after the operation 135
osteotomy/realignment 137–8
purposes of 128
recovery from 136
timing of 128–9
swelling 23
symptoms and signs 5, 21–7, 29, 30–1
crepitus 23
feet OA 27
hand OA 26–7
hip OA 27
knee OA 25
muscle weakness 23–4
pain 22
patient perspective 61–3
range of motion, reduction in 23
shoulder OA 27
in specific joints 24–7
spine OA 25–6
stiffness 22–3

191Index
swelling 23
tenderness 23
synovial fluid 5, 6, 7, 23, 34
synovial joints 4, 5–6
with mild OA 6, 7f
normal 6f
with OA 4, 5–6
with severe OA 7–8, 7f
synovium 5, 6f, 7f, 8
T
t'ai chi 75–7
tenderness of joints 23
tendons 6
tenoxicam 105
thoughts 144, 144f, 145
positive and negative 143, 144
worry 145
thumbs 27, 46, 125
tissue engineering 58–9, 59f
total hip replacement (THR) 45,
129, 134
'pseudo-tumour' 131
see also arthroscopy
total joint replacement 132
total knee replacement (TKR) 129, 132f, 134
prosthesis 130f
see also arthroscopy
traction 72
transcutaneous electrical nerve stimulation
(TENS) 120
treatments 53
disease process, altering 60
knee bracing 58, 58f, 121, 122–3, 123f,
124f
non-pharmacological 54–5
obesity prevention 59
orthotics 58, 121
pharmacological therapies 55–6
steps 53, 54f
tissue engineering 58–9, 59f
see also management, of OA; surgery
tricyclics (TCAs) 151, 151t
U
unicompartmental replacement 132, 132fV
valgus braces 121, 122, 123
valgus (knock knees) 43, 44f
varus (bow legs) 43, 44f
vertebrae 25–6
Vioxx® (rofecoxib) 108
vitamins 15, 55–6, 81, 87, 101, 116–7, 118
A 86
C 15, 116
D 15–6, 81, 85, 87, 101, 116–7
E 15, 116
K 81, 87
W
waist circumference 82
walking frames 120, 121f
walking, postural alignment 30
walking sticks 121f
walking training 161
warfarin 116
water aerobics 66–7
water therapy 72
'wear and tear' 8
websites 150
wedged insoles 121–2
weight control 54–5, 81–5
and body mass index (BMI) 82
calories 83, 84
diet and weight loss 79–89
exercise 84–5
fats, eating less 83–4
fruit and vegetables 83, 84
losing weight 82–3
risk factors for OA 81–2
sugar 84
waist circumference 82
weight-loss medications 85
weight training 67
worry 145
wrists 5, 44f, 138
X
X-rays 31–2, 33f
Y
yoga 74–5

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