Strengthening and aerobic exercises (e.g., fitness walking) have been shown in numerous trials to reduce pain and disability while improving quality of life. The FAST confirmed the beneficial effects of quadriceps strengthening and aerobic exercise in patients with knee OA.³ Felsen reported that a decrease of 2 BMI units (˜11.2 lbs) over 10 years in a group of women above median BMI decreased the odds of developing OA by over 50%.⁴

To promote self-efficacy, psychological well-being, and improved pain levels, patients should be encouraged to participate in programs such as the Arthritis Foundation Self-Help Course.⁵ For patients who are poorly tolerant of weight-bearing exercises due to their OA, aquatic exercises may be an alternative. (Swimming, however, may worsen lumbar facet arthritis symptoms.) Physical modalities and judicious rest between sessions may also improve tolerance and compliance with exercises.

A cane held in the hand contralateral to a painful hip can help unload the joint and make ambulation more bearable. For a painful knee, the cane can be held in either hand.⁶ Knee unloading braces and lateral heel wedges can reduce stress in the medial knee compartment and relieve pain. Environmental adaptations include raising toilet and chair heights.

Pharmaceutical agents are most effective when combined with nonpharmacologic strategies.⁷ A trial of acetaminophen is recommended as the initial treatment for mild to moderate hip OA or knee OA without gross inflammation because of its overall cost, efficacy, and toxicity profile.⁷ For patients with moderate to severe knee OA and signs of joint inflammation,
IA steroids, COX-2 inhibitors, or NSAIDs (with misoprostol or a proton pump inhibitor if the patient is at risk for adverse upper gastrointestinal events) may be considered as first-line therapy.⁷

Tramadol can be considered in patients with moderate to severe pain with contraindications to NSAIDs/COX-2 agents and/or failing other treatments. The mean effective daily dose for tramadol has generally been ˜200 to 300 mg, divided into four doses.⁶ More potent opioids can be considered for patients not tolerating or failing tramadol.

Topical analgesics (e.g., methyl salicylate or capsaicin) can be considered in patients with mild to moderate knee OA pain as an adjunctive treatment or as monotherapy. Voltaren (diclofenac) gel is also available to treat the pain of OA of both knees and hands; IA hyaluronan therapy (e.g., Synvisc) is indicated for patients with knee (not hip) OA with a poor response to simple analgesics and nonpharmacologic treatment. Studies of IA hyaluronan are somewhat controversial and inconclusive, but generally seem to favor its use in mild to moderate knee OA. Peak effects may be at 8 to 12 weeks; duration of action may be up to 6 months. Limited data are available regarding the efficacy of multiple courses of IA hyaluronan. IA glucocorticoids fluoroscopically guided into the hip joint may be efficacious in some patients.⁷

Complementary and alternative medicine treatments abound. Although preliminary studies of glucosamine/chondroitin appeared promising at providing modest short-term symptomatic improvement, a recent NIH-sponsored multicenter trial (GAIT) did not show benefit in pain, function, or radiologic progression in over 1,500 patients with knee OA.⁸ Research on the efficacy of acupuncture in OA is likewise promising but qualitatively suboptimal. Other complementary treatments currently under investigation include supplementation with vitamin D and the antioxidant vitamins A, C, E, and coenzyme Q10, and curcumin-phosphatidylcholine.

A recent development in the surgical treatment of knee OA is the UniSpacer, which is FDA approved for isolated, moderate, medial compartment OA. The kidney bean-shaped lightweight metallic alloy device is a self-centering bearing that requires no shaving of bone or screw/cement fixation to the native anatomy. Long-term efficacy is under investigation, though early clinical studies are disappointing with high revision rates and only modest relief of pain.⁹