What are the recommended approaches for arthritis management?

Recommended Approaches for Arthritis Management

The optimal management of arthritis requires a comprehensive, multimodal approach including exercise, weight management, self-management programs, appropriate orthoses, and pharmacologic interventions tailored to the specific type of arthritis and affected joints. 1

Core Interventions for All Arthritis Patients

Exercise Therapy

• Strong recommendation for regular exercise programs for all patients with osteoarthritis (OA) of the hand, hip, and knee 1
• Exercise options should include:
  • Walking, strengthening exercises, neuromuscular training, and aquatic exercise for knee and hip OA 1
  • Supervised exercise programs yield better outcomes than unsupervised ones 1
  • Tai chi is strongly recommended for all OA patients 1
• Exercise improves disease activity, reduces symptoms like pain and fatigue, and enhances function and mental health 2, 3

Weight Management

• Strong recommendation for weight loss in patients with knee and/or hip OA who are overweight or obese 1
• Weight management is a key preventive strategy in the absence of disease-modifying agents 1

Self-Management Programs

• Strong recommendation for self-efficacy and self-management programs 1
• These programs can significantly improve physical function and pain management 1
• Should include education about arthritis, coping strategies, and activity pacing 1

Joint-Specific Interventions

Hand Arthritis Management

• Strong recommendation for first carpometacarpal (CMC) joint orthoses (neoprene or rigid) 1
• Conditional recommendation for orthoses for other hand joints 1
• Conditional recommendation for kinesiotaping for first CMC OA 1
• Topical NSAIDs, intraarticular steroid injections, and chondroitin sulfate are conditionally recommended for hand OA 1

Knee Arthritis Management

• Strong recommendation for tibiofemoral bracing for tibiofemoral OA 1
• Conditional recommendation for patellofemoral bracing for patellofemoral OA 1
• Strong recommendation for cane use to improve mobility 1
• Strong recommendation for topical NSAIDs for knee OA 1
• Strong recommendation for intraarticular glucocorticoid injections 1
• Conditional recommendation for topical capsaicin 1

Hip Arthritis Management

• Strong recommendation for intraarticular glucocorticoid injections 1
• Walking aids (canes) strongly recommended to improve mobility and function 1

Pharmacologic Management

First-Line Options

• Strong recommendation for topical NSAIDs for knee OA (lower systemic exposure) 1
• Strong recommendation for oral NSAIDs for hand, knee, and hip OA 1
  • Naproxen has demonstrated efficacy in controlling joint swelling, reducing morning stiffness, and improving mobility in OA patients 4
  • Begin with lowest effective dose to minimize gastrointestinal and cardiovascular risks 1

Second-Line Options

• Conditional recommendation for acetaminophen (lower efficacy but safer profile for some patients) 1
• Conditional recommendation for duloxetine for pain management 1
• Conditional recommendation for tramadol when other options have failed 1

Additional Therapeutic Approaches

Mind-Body Interventions

• Conditional recommendation for yoga 1
• Conditional recommendation for cognitive behavioral therapy 1
• Conditional recommendation for acupuncture 1

Physical Modalities

• Conditional recommendation for thermal modalities 1
• Conditional recommendation for massage therapy 1
• Conditional recommendation for balance exercises 1
• Conditional recommendation for radiofrequency ablation for knee OA 1

Implementation Considerations

Assessment Approach

• Evaluate for medical conditions that might impact treatment choices:
  • Hypertension, cardiovascular disease, heart failure, gastrointestinal bleeding risk, chronic kidney disease 1
  • Disease severity, surgical history, and access to services 1

Treatment Selection Algorithm

1. Start with non-pharmacologic interventions (exercise, weight management, self-management) for all patients 1
2. Add appropriate orthoses based on affected joints 1
3. For persistent symptoms, add topical therapies before systemic medications 1
4. Progress to oral medications starting with NSAIDs if no contraindications 1
5. Consider intraarticular injections for specific joint involvement 1
6. Add mind-body and additional integrative approaches as needed 1

Common Pitfalls to Avoid

• Focusing solely on pharmacologic management without addressing exercise and weight management 1
• Failing to provide specific exercise recommendations and supervision 1, 5
• Not addressing psychosocial aspects of chronic pain management 1
• Using opioids before exhausting safer alternatives 1
• Not tailoring interventions to the specific joint(s) affected 1

Special Considerations

• Patients may experience additional symptoms such as mood disorders, altered sleep, and chronic widespread pain that require addressing as part of the treatment plan 1
• When choosing pharmacologic therapies, begin with treatments having the least systemic exposure or toxicity 1
• Regular monitoring and adjustment of the treatment plan is necessary as arthritis is a progressive condition 1