MANAGEMENT

 The principles of treatment of chronic pain in general

include the following (WHO):
 the underlying cause of pain should be treated whenever
possible
 oral medicines are among the key components of pain
management
 some medicines should be given regularly ("by the clock")
 a recognition that therapeutic regimes need to be
individualised with attention to detail and combined with
psychological support e.g. cognitive behavioural techniques
 the necessity to monitor and evaluate for therapeutic and
unwanted effects.
Grainger, Rebecca and Flavia M Cicuttini.
Medical management of osteoarthritis of the
knee and hip joints. MJA 2004; 180 (5): 232-
236
NON PHARMACOLOGIC MANAGEMENT
 The mainstay of treatment involves altering loading
across the joint since OA is a mechanically driven
disease
 (1) avoiding activities that overload the joint, as
evidenced by their causing pain;
 (2) improving the strength and conditioning of muscles
that bridge the joint, so as to optimize their function
 (3) unloading the joint, either by redistributing load
within the joint with a brace or a splint or by unloading
the joint during weight bearing with a cane or a crutch
(Harrison’s
NON PHARMACOLOGIC MANAGEMENT
 Education
 present with journal articles, evidence
 Weight Loss
 corresponding multiplier effect, unloading both knees and hips
 Unloading the Joint
 Cane
 Insoles - Insoles may also limit disease progression by reducing
forces across the hip joint
 Exercise – ex. Aquatic therapy
 Acupuncture
 RCT: significantly reduced pain and improved quality-of-life
scores by 30 to 50% for the 3-month treatment period
 benefit was maintained after 3 months of follow-up (Witt et al)
PHARMACOLOGIC MANAGEMENT
Drugs Mechanism Indicatio Current Adverse Effects Recommen
of Action n Dose ded Dose
Acetaminop inhibition of OA pain 650 mg High dose: GI Maximum
hen COX (1st line) twice a tox, liver damage dose= 4
day long-term use: g/day
monitor clotting (Increase)
measures in
patients
taking
anticoagulant
agents
Celecoxib Selective OA pain 400mg/da Increased risk for Reduce to
Inhibition of y MI and stroke 200mg)
COX2 compared to Non
selective
NSAIDs,
intravascular
thrombosis
Drugs Mechanism Indication Current Adverse Recommen
of Action Dose Effects ded Dose
Tramadol Weak opioid Nociceptive, 50mg twice flushing, 50 mg every
agonist, Neuropathic a day headache, 6 hr, up to
inhibits Pain dizziness, 300 mg a
reuptake of insomnia, day
NE and muscle (immediate
serotonin weakness, release)
and
constipation
Pregabalin analog of Neuropathic 50 mg/ Dizziness, 75-150 mg
GABA pain bedtime drowsiness bid. May
modulation visual increase up
of Ca disturbance to 600
channels (BOV, mg/day in
and diplopia), patients with
reduction in etc ongoing
the release pain and can
of several tolerate 300
neurotransm mg/day
itters
TRAMADOL (FOR CHRONIC
MUSCULOSKELETAL PAIN)
 should be given by mouth and by the clock;
 the initial dose should be titrated upward gradually to
reach the individual level required for suitable pain
control
STRONG OPIOIDS?
 limited evidence for the effectiveness of strong opioids
in reducing pain in osteoarthritis
 lack of trials comparing strong opioids with each other in
osteoarthritis, and assessing longer-term use
 if a strong opioid is needed as adjunctive treatment for
osteoarthritic pain, its use should be relatively short-term
pending surgical or other specialist referral.
 (Pocock, 2008)
 strong opioids reduce severe osteoarthritis pain by
approximately 24%
 The small to moderate beneficial effects of non-tramadol
opioids are outweighed by large increases in the risk of
adverse events.Non-tramadol opioids should therefore
not be routinely used, even if osteoarthritic pain is
severe. (Nuesch et al)
INTRAARTICULAR INJECTIONS: GLUCOCORTICOIDS
AND HYALURONIC ACID

 Glucocorticoids : pain relief for 1-2 weeks up to 1500

mg/ day
 chondroitin, up to 1200 mg a day
SURGERY
 Total hip replacement
 Resurfacing Arthoplasty
MANAGEMENT OF LUMBAR
RADICULOPATHY
 Physical therapy and exercise, which generally is best done in a
controlled, progressive manner and will include some combination of
stretching, strengthening and cardio conditioning
 Massage therapy

 Appropriate changes in behavior, ergonomics and environment (for

example cushioning, chair and desk height, sleeping position).
 Analgesics

 Anticonvulsant (pregabalin)

 Epidural steroid injections to deliver local anti-inflammatory agents

(and possibly a pain medication) directly to the affected area.
 Numbing medication and steroid (anti-inflammatory) next to the nerve

 Alternative medicine treatments (chiropractic or osteopathic

manipulation)
SURGERY
 standard lumbar microdiscectomy for decompression
CONCLUSION
 Optimal therapy – trial and error
 Each patient has a different response

 If medical interventions fail surgical interventions

SOURCES
 Grainger, Rebecca and Flavia M Cicuttini. Medical management of osteoarthritis of the
knee and hip joints. MJA 2004; 180 (5): 232-236
 
 Harrison’s Principle of Internal Medicine 17th edition

 Hinman RS, Heywood SE, Day AR. Aquatic physical therapy for hip and knee
osteoarthritis: results of a single-blinded randomized controlled trial. Phys Ther
2007;87:32-43.
 
 Lane, Nancy. Osteoarthritis of the Hip. n engl j med 2007; 357;14
 Pocock, Nicola. DTB reviews strong opioids for osteoarthritis in primary care. Drug and
Therapeutics Bulletin 2009;47:138-141

 Reig E. Tramadol in musculoskeletal pain: A survey. Clinical rheumatology 2002, vol. 21

 Witt CM, Jena S, Brinkhaus B, LieckerB, Wegscheider K, Willich SN. Acupuncturein
patients with osteoarthritis of theknee or hip: a randomized, controlled trial with an
additional nonrandomized arm.Arthritis Rheum 2006;54:3485-93