What are the initial management recommendations for osteoarthritis?

Initial Management Recommendations for Osteoarthritis

The initial management of osteoarthritis should focus on a multicomponent approach that includes education, exercise, and weight management as core treatments before considering pharmacological interventions. 1, 2

Core Non-Pharmacological Treatments

Education and Self-Management

• Provide patients with appropriate information (both oral and written) about osteoarthritis to enhance understanding and counter misconceptions about the condition 1
• Offer education on self-management strategies that should be included and reinforced at subsequent clinical encounters 1, 2
• Develop an individualized management plan in partnership with the patient, considering their specific needs, preferences, and capabilities 1
• Target positive behavioral changes such as activity pacing (avoiding "peaks" and "troughs" of activities) 1

Exercise

• Prescribe an individualized exercise program that includes:
  • Local muscle strengthening exercises 1, 2
  • General aerobic fitness activities 1, 2
  • Flexibility and neuromotor exercises (balance, coordination) 1, 2
• Select the mode of delivery (individual/group, supervised/unsupervised, face-to-face/digital, land-based/aquatic) according to local availability and patient preferences 1
• Ensure adequate exercise dosage with appropriate progression tailored to physical function 1

Weight Management

• Provide education on the importance of maintaining a healthy weight 1, 2
• Offer support to achieve and maintain weight loss for patients who are overweight or obese 1, 2

Adjunct Non-Pharmacological Treatments

• Consider local heat or cold applications for symptomatic relief 1
• Evaluate for appropriate assistive devices:
  • Walking aids (canes) to improve mobility 1, 2
  • Bracing or joint supports for biomechanical joint pain or instability 1, 2
  • Appropriate footwear with shock-absorbing properties 1
• Consider transcutaneous electrical nerve stimulation (TENS) for pain management 1
• For hip osteoarthritis specifically, consider manipulation and stretching techniques 1

Initial Pharmacological Management

• Start with acetaminophen (paracetamol) for pain relief, using regular dosing up to 4,000 mg/day 1, 3
• For knee and hand osteoarthritis, consider topical NSAIDs before oral NSAIDs, particularly in patients ≥75 years old 1, 3
• If acetaminophen or topical NSAIDs provide insufficient pain relief, consider:
  • Oral NSAIDs at the lowest effective dose for the shortest possible period 1
  • COX-2 inhibitors with a proton pump inhibitor to minimize gastrointestinal risks 1, 3
  • Topical capsaicin as an alternative 1

Common Pitfalls to Avoid

• Relying solely on pharmacological treatments without implementing core non-pharmacological approaches 2
• Failing to assess the biopsychosocial impact of osteoarthritis on function, quality of life, mood, and participation 1
• Initiating oral NSAIDs without considering gastrointestinal, liver, and cardiorenal risks, especially in elderly patients 1
• Using glucosamine and chondroitin products, which are not recommended due to insufficient evidence of benefit 1
• Neglecting regular follow-up and adjustment of the treatment plan based on patient response 1, 2

Implementation Algorithm

1. Start with education, self-management strategies, and exercise for all patients 1, 2
2. Add weight management interventions for overweight/obese patients 1, 2
3. Consider appropriate assistive devices and physical modalities based on individual needs 1, 2
4. If pain persists, initiate acetaminophen or topical NSAIDs 1, 3
5. Progress to oral NSAIDs with appropriate gastroprotection if needed 1
6. Consider referral for specialized interventions if symptoms remain inadequately controlled 2