What are the recommended approaches for arthritis management?

Recommended Approaches for Arthritis Management

The cornerstone of arthritis management includes regular exercise programs, weight management for overweight patients, and self-management education, supplemented by appropriate orthoses, topical and oral medications as needed, following a stepwise approach based on joint involvement and symptom severity. 1, 2

Core Interventions

• Regular exercise programs are strongly recommended for all arthritis patients, including walking, strengthening exercises, neuromuscular training, and aquatic exercise to improve pain and function 1, 2
• Weight loss is strongly recommended for overweight or obese patients with knee and/or hip osteoarthritis (OA) to reduce joint load and improve symptoms 1, 2
• Self-efficacy and self-management programs should be provided to all patients to enhance understanding of arthritis, develop coping strategies, and learn activity pacing 1, 2

Joint-Specific Interventions

• For hand OA, first carpometacarpal (CMC) joint orthoses are strongly recommended, while orthoses for other hand joints and kinesiotaping are conditionally recommended 1, 2
• Tibiofemoral bracing is strongly recommended for tibiofemoral OA, and patellofemoral bracing is conditionally recommended for patellofemoral OA 1, 2
• Cane use is strongly recommended to improve mobility in patients with knee and hip OA 1, 2
• Local heat or cold applications can provide symptomatic relief for affected joints 2

Pharmacologic Management

• Topical NSAIDs are strongly recommended for knee OA as first-line pharmacologic therapy due to their effectiveness with minimal systemic exposure 1, 2, 3
• Oral NSAIDs (like naproxen) are strongly recommended for hand, knee, and hip OA, but should be used at the lowest effective dose for the shortest duration due to potential gastrointestinal and cardiovascular risks 1, 2, 4
• Acetaminophen is conditionally recommended as a second-line option for mild to moderate pain, though recent guidelines have downgraded its importance due to limited efficacy 2, 3
• Duloxetine and tramadol are conditionally recommended as second-line options when other treatments have failed 1, 2
• Intra-articular corticosteroid injections are recommended for acute pain flares, especially with effusion 2, 3

Additional Therapeutic Approaches

• Mind-body interventions, including yoga, cognitive behavioral therapy, and acupuncture, are conditionally recommended for OA management 1, 2
• Physical modalities such as thermal treatments, massage therapy, and balance exercises are conditionally recommended 1, 2
• Lifestyle modifications including a Mediterranean diet rich in fruits, vegetables, whole grains, and nuts may help reduce inflammation associated with arthritis 5

Treatment Algorithm

1. Start with core interventions for all patients:

   • Exercise program tailored to joint involvement and patient capabilities 1, 2
   • Weight management for overweight/obese patients 1, 2
   • Self-management education 1, 2

2. Add physical modalities based on joint involvement:

   • Appropriate bracing, orthoses, and assistive devices 1, 2
   • Local heat/cold applications 2

3. Add topical therapies for accessible joints:

   • Topical NSAIDs, especially for knee OA 1, 2

4. Progress to oral medications if response is inadequate:

   • Oral NSAIDs at lowest effective dose 1, 2, 4
   • Consider acetaminophen or duloxetine if NSAIDs are contraindicated 1, 2
   • Reserve tramadol for refractory cases 1, 2

5. Consider intra-articular injections for persistent symptoms or flares 2, 3

Important Considerations and Pitfalls

• Regular physical activity is crucial but often underemphasized; patients with arthritis typically have decreased physical activity levels despite its benefits for cardiovascular health, disease activity, and psychological wellbeing 6
• NSAIDs should be used cautiously due to potential side effects; naproxen has been shown to have comparable efficacy to other NSAIDs but with fewer mild gastrointestinal and nervous system adverse effects 4
• Avoid combining naproxen with aspirin as this may increase naproxen excretion and potentially increase adverse events 4
• Biologic agents like adalimumab are not first-line treatments for osteoarthritis but may be considered for inflammatory arthritis such as rheumatoid arthritis when conventional treatments fail 7
• Glucosamine and chondroitin products are not recommended by most guidelines despite popular use 2
• Athletic activities should be modified rather than eliminated; recommended activities include swimming, hiking, bicycling, walking, and golfing rather than high-impact activities 8