- Obesity (58,78,94).
- Fear that exercise will aggravate their pain (58).
- Age (78).
- Greater proprioceptive inaccuracy (for knee OA) (78).
- Higher pain intensity (78).
- Concomitant disorders, especially pulmonary diseases, other mobility problems (94).
- Joint malalignment or laxity (24,78).
- Muscle imbalances (22,24).
|Alleviating Factors and Treatment Options
- There is no set combination of medications that will consistently relieve pain for all people with OA (63).
- Paracetamol (some say acetaminophen) as first-line defense followed by NSAIDs or COX-2 inhibitors if paracetamol fails to provide adequate pain relief (28,63,94).
- Two well-designed studies of oral glucosamine sulfate confirmed a 20% to 25% reduction in pain in patients with mild to moderate knee OA (28).
- Topical application of glucosamine sulfate and chondroitin sulfate may be effective in reducing pain from knee OA (28).
- Opioids, such as codeine, in combination with paracetamol can provide better pain relief but are not tolerated well, requiring discontinuation of opioids by up to a third of people prescribed this regimen (28,63).
- Synthetic opioids, like tramadol, are better tolerated but are contraindicated in seizure disorders (28,63).
- Intra-articular injections of synthetic long-chain hyaluronan preparations for knee OA decrease pain over 6 months but are very expensive and not covered by insurance, limiting their widespread application (28,63).
- Intra-articular injections of glucocorticoids usually provide a modest short-lived decrease in pain. However, in some patients there are dramatic and sustained results, but there is no way of predicting which people will respond (28,63).
- Intra-articular injections of steroids are not particularly effective for reducing pain in OA (28).
- Topical capsaicin has a modest pain-relieving effect for knee OA either alone if systemic analgesics are not tolerated, or in combination with simple analgesics (28,63,95).
- Use of topical agents in hip OA have not been studied. Intra-articular injections of glucocorticoids have not been well studied for hip OA and intra-articular hyaluronic acid is not approved for hip OA (28).
- A review of 7 randomized controlled trials has shown that transcutaneous electrical nerve stimulation (TENS) may offer effective pain relief for people with OA of the knee (24).
- In a double-blind randomized control trial, infrared low-power Gallium-Arsenide (Ga-As) laser therapies in conjunction with exercise offered significantly more pain relief than placebo (30).
- Physical strategies such as exercise, physiotherapy, physical therapy, hydrotherapy, swimming, thermal therapy, and massage (58,63,78,94).
- Assistive devices such as canes, walkers, orthotics, wedged insoles, taping and unloader braces may reduce pain by addressing abnormal biomechanics, joint malalignment, and muscle imbalances (63).
- Self-efficacy - belief in one's capacity to meet given demands (78).
- Social support (63,78).
- Weight reduction if overweight or obese (28,63).
- Education of disease process, exercise instruction, prognosis and rationale, and implications of managing their condition. In many cases, education is as effective in managing pain as NSAIDs (28,63,94).
- Total joint arthroplasty relieves pain and improves function over at least a decade. Revision arthroplasty is more complicated, so it may be best to postpone arthroplasty in younger people with OA (28,94).
Other promising alternative treatment approaches that need further study to verify effectiveness and efficacy in treating pain in OA:
- Pulsed electro-magnetic fields to manage pain in knee OA (24).
- Devil's claw (H. procumbens) has shown favorable results in pain relief in 8 randomized controlled trials (RCTs) for OA and other musculoskeletal conditions (20,95).
- Avocado-soybean unsaponifiables shows favorable results in 4 RCTs (20, 95).
|Specific Exercise Guidelines to Manage Pain
- There are many possible reasons for OA pain. The ability to accurately identify the cause of OA pain significantly increases the ability to manage pain (63).
- OA at different sites requires different approaches. Range of motion exercises may increase pain in OA of the hip, and knee extension exercises can increase pain in OA of the knee. Modify the program as symptoms or disease activity change (28, 63).
- Knee pain in OA has been most frequently studied. Hip pain to a lesser extent (49,73).
- At least in the short term, exercise improves pain, muscular strength, and function in older people with mild OA of the knee or hip (49).
- In the long-term, people with knee and hip OA can experience a substantial reduction in pain through a comprehensive inpatient rehabilitation program followed by an individualized home-based program. Other reviews indicate that there is not enough evidence to draw this same conclusion for hip OA (24,58,73).
- While this benefit is true, it is based on averages. There will be individuals whose pain may worsen with exercise (58).
- Avoid exercise associated with greater risk of injury or high-impact loads (49).
- The goal of exercise program for a person with OA is to reduce pain and disability by strengthening muscle, improving joint stability, increasing the range of movement, and improving aerobic fitness (28).
- Exercise programs have varied widely in studies leaving insufficient data to offer specific recommendation on optimal dosage or optimal program content (49,73).
- Like all populations, both disabled and non-disabled, long-term compliance to exercise is critical to long-term health benefits and reduction in pain. As compliance declines, pain may increase (49,58,94).
- A contributing factor in lack of compliance may be the difficulty in maintaining standard exercise and dietary weight loss programs in previously sedentary, overweight adults with mobility challenges (58).
- People with arthritis that exercised in their youth perceive greater benefits from exercise and may be more compliant (94).
- Adherence problems may be greater in home-based programs vs. facility-based programs although other studies indicate they are similarly effective. The benefit of the home-based programs appears to be highly associated with the frequency of home monitoring (24,49,94).
- A randomized controlled clinical trial showed ineffective pain improvement from a 6-month home-based exercise program (5 exercises over 30 minutes, 4x per week) primarily due to noncompliance (73).
- Supplementing a home exercise program with a group class appears to increase compliance and reduce pain more effectively in the long-term than home-based exercise alone (57).
- If knee replacement occurs, participation in no-impact or low-impact sports is fine, but participation in high-impact sports should be prohibited. (49)
- The combination of diet and exercise produced greater pain relief after an 18-month intervention than either diet or exercise alone (58).
- Both high- and low-intensity stationary cycling have been shown to improve pain with OA of the knee (49).
- Both isokinetic and progressive resistance exercise improve pain, although progressive resistance exercise showed a little better improvement. It also has the benefit of being less expensive, more easily performed, and more efficient than isokinetic exercise (22).
- Progressive muscle strengthening is shown in multiple studies to reduce pain in OA. Home-based strengthening programs also shown to be effective in reducing pain in compliant people with OA (49,67).
- A 6-month home-exercise strength-training program resulted in a reduction of pain in OA of the knee with the most relief achieved from those who were most compliant (67).
- In a small randomized, controlled trial (n=17), yoga was shown to reduce hand pain in OA and decrease tenderness of finger joints (20).
- Stretch tight muscles and maintain existing range of motion (49).