I HAVE OSTEOARTHRITIS: NOW WHAT?

Osteoarthritis is the most common form of arthritis and it’s affecting more and more Canadians every year. It’s estimated that by 2035, one in four Canadians with be diagnosed with osteoarthritis – a disease of the whole joint that leads to the breakdown of joint cartilage and the underlying bone.

Osteoarthritis (OA) is sometimes described as degenerative or “wear-and-tear” arthritis. Recent studies suggest there may be an inflammatory component to OA, so it may not just be age-related or caused by overuse. In normal joints, cartilage – the tough elastic material that covers and protects the ends of bones – acts as a cushion and provides a smooth, gliding surface for joint motion. OA causes the cartilage to break down, leading to pain, swelling, and problems moving the joint. As it worsens over time, the cartilage wears away and bone rubs against bone, causing joint damage and increased pain.

HOW IS THE SEVERITY OF OA DETERMINED?

OA usually progresses slowly over months or years and early symptoms tend to come and go. It commonly affects the knees, hips, first toes, wrists, thumbs, fingers, and spine. As damage progresses, symptoms can become more constant, occurring at rest and disturbing sleep.

There are a number of methods for classifying the clinical severity of OA, which is important in directing appropriate treatment. The most commonly used is Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) that assesses OA based on pain, stiffness, and physical function.

There are also different methods for determining the severity of OA through imaging. The Whole-Organ Magnetic Resonance Imaging Score (WORMS) method provides a whole-organ assessment of OA using MRI to look at 14 different features of soft tissue within the joint, such as articular cartilage integrity, subarticular bone marrow abnormality, subarticular cysts, etc.

As X-ray is a readily available type of medical imaging that is very good at looking at bones, the Kellgren-Lawrence grading scale is routinely used to gauge OA disease severity. It is determined by assessing joint space narrowing and bony growths, and is divided into five stages – stage 0 to 4.

WHAT ARE THE STAGES OF OA AND TREATMENT OPTIONS?

STAGE 0 – Joint is healthy and there are no signs of OA.

STAGE 1 – Some development of bony growths (bone spurs) within the joint. At this stage, there is only minor wear on joint components, and you rarely experience pain or discomfort.

• Treatment: If there are minor symptoms, or you have other factors putting you at an increased risk of OA, oral supplements and an exercise regime may be recommended to slow the progression of the disease. Weight loss, bracing to ensure joint stability, and oral pain relief medication may be prescribed at any stage. A platelet-rich plasma (PRP) Injection, which uses plasma from your own blood to stimulate your body to heal itself, may also be recommended to help repair damage during this early stage.

STAGE 2 – This is considered mild OA. X-rays will show larger bone spurs, but cartilage is still thick enough to prevent the bones from rubbing against one another. Synovial fluid, which helps lubricate and cushion joints, is typically still present at sufficient levels for normal joint motion. It’s often at this stage where you may first begin experiencing symptoms. They could include pain after a long day of walking or running, greater stiffness in the joint when it’s not used for several hours, or tenderness when kneeling or bending.

• Treatment: For OA at this stage, effective treatments usually include weight loss, low-impact aerobics and strength training, braces and wraps to help stabilize joints, and oral nonsteriodal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, which help relieve pain and inflammation but can cause stomach irritation. Joint injections with viscosupplements or PRP may also be effective at this stage.

STAGE 3 – Classified as moderate OA, cartilage between bones shows obvious damage and thinning so the space between the bones begins to narrow. You may experience frequent pain when using the joint, or stiffness after long periods of inactivity or when waking up in the morning. Joints may swell after extended periods of motion, as well.

• Treatment: At this point over-the-counter medication or NSAIDs may not be adequate to manage pain relief. Your doctor may recommend steroid injections, which locally introduce a corticosteroid (an anti-inflammatory medication) to decrease inflammation and reduce pain. During this procedure a small dose of steroids is injected into the joint under image guidance to keep potential side effects to a minimum. Results can last from weeks to months depending on the joint involved, severity of the arthritis, and the specific cause of pain. Some patients get complete relief after a single injection. Unfortunately, steroids may become less effective with repeated injections and may have effects on the rest of your body over time.
• Sometimes narcotics are prescribed on a short-term basis to treat moderate to severe pain, but they are not recommended for long-term use due to the risk of increased tolerance and possible dependence. Side effects of these medicines include nausea, sleepiness, and fatigue.
• Viscosupplement injections may also be a treatment option, on their own or in conjunction with cortisone injections. This procedure involves the injection of hyaluronic acid (HA) – a viscose substance normally present in healthy joints, but decreased in OA. When injected into affected joints, these gel-like substances improve mobility, reduce pain, and lubricate the joint. They also have a mild anti-inflammatory effect. As with all injections, they are best performed under image guidance to ensure the solution is delivered exactly where you need it. The relief may take a few weeks. Occasionally, patients may experience a post-injection flare after HA with increased pain, and stiffness. This could be due to the viscosity of the injection and settles with oral anti-inflammatories or a subsequent steroid injection.

STAGE 4 – At this stage, OA is considered severe and you may experience great pain and discomfort when using the affected joint, or during rest. The joint space between bones is dramatically reduced and the cartilage is often completely gone, leaving the joint stiff and possibly immobile. Synovial fluid can be decreased dramatically, no longer reducing the friction between the bones, or can be increased, limiting range of motion of the joint.

• Treatment: For stage 4 OA, treatment often involves surgery, such as joint fusion or, more commonly, joint replacement surgery. Steroid or HA injections may provide temporary symptom relief for patients awaiting surgery, or can help manage symptoms longer term for those who decide against or cannot have surgery.

Osteoarthritis is a chronic (long-term) disease and, although there is no cure, treatment can help reduce your symptoms and make it possible for you to lead a full and active life. Studies suggest treatment in early stages of the disease is the most effective way to prevent progression. In most cases, you can manage mild to moderate arthritis symptoms for many years with a treatment plan. It’s also important to thoroughly discuss all your option with your health care practitioner, especially in the later stages of the disease.

For more information on pain management procedures, please speak to your health care practitioner.

REFERENCES

Arthritis Foundation (2021) “Osteoarthritis.” www.arthritis.org. Accessed December 6, 2021.

Arthritis Society Canada (2021) “Osteoarthritis.” www.arthritis.ca. Accessed December 6, 2021.

Bennington-Castro, J. (2020) “What Is Osteoarthritis? Symptoms, Causes, Diagnosis, Treatment, and Prevention.” www.everyday.health. Accessed December 6, 2021.

Holland, K. (2021) “Stage of Osteoarthritis of the Knee.” www.healthline.com. Accessed December 6, 2021.