Many people who develop knee pain from osteoarthritis (OA) get good relief from simple lifestyle changes like getting more exercise and from over-the-counter treatments like knee braces and shoe inserts, according to the results of a new study.
But many people with arthritis also start taking pain medications without any guidance from a doctor or pharmacist, a decision that may lead them to over-the-counter drugs that could aggravate common conditions like heart disease, hypertension and stomach ulcers.
“I think it’s really good that people felt empowered to do things on their own. The scary thing is when they start to do the medication part on their own without advice,” says lead author Carlo Marra, PhD, a pharmacist and a research scientist at the Arthritis Research Center of Canada in Vancouver.
For this study, which was published in 2010 in Arthritis Care & Research, pharmacists at 27 locations in Canada recruited customers who’d complained of knee problems in the past year. They gave them a screening questionnaire and based on those answers, identified 190 people who had knee OA but had never been diagnosed with it. These participants were mostly overweight or obese white women with an average age of 63 years. Researchers assessed these patients at the beginning of the study and again one, three and six months after diagnosis.
When they first joined the study, less than half of the participants were doing any sort of exercise, but after six months, nearly three-quarters said they were routinely exercising and 80 percent said it made them feel better.
Additionally, by the end of the study, about one-third had begun using knee braces, shoe inserts, knee tape and acupuncture and 75 percent said those remedies made a difference, and nearly all reported seeing a doctor to talk about their knee pain.
Experts said they were surprised to see that more than 50 percent of participants started treatment – whether exercise, activity aids or medicines – on their own.
“My first impression of the study is that it really proves that patients are smarter than we give them credit for,” says Neeru Jayanthi, MD, director of Sports Medicine at Loyola University Health System, in Chicago, who was not involved in the research. “What we are finding here is patients are directing themselves to increase their own quality of life and they have been relatively successful.”
But researchers stressed that going it alone might not always be a good idea, particularly when it comes to taking medications.
During the study, 52 percent of study participants started some sort of pain medication, 36 percent took natural medicine supplements and 66 percent took a combination of both. About half used nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Motrin) or naproxen (Alleve) and about a quarter tried acetaminophen (Tylenol).
Researchers say they were troubled to learn that more patients starting using NSAIDs before trying acetaminophen, which the American College of Rheumatology recommends as the first line of therapy for OA, because when used as directed, it associated with fewer side effects that NSAIDs.
“Acetaminophen is much safer,” Marra says. “People with knee OA tend to be older and might have hypertension or heart failure, which might be exacerbated by NSAIDs. NSAIDs also have impact on gastrointestinal safety. They can lead to ulcers. Acetaminophen doesn’t have those problems and about half who take it respond to it,” he adds.
When it came to natural supplements, 60 percent of participants took glucosamine and 40 percent used both glucosamine and chondroitin. Marra says these results point out a need for doctors to educate patients about these medications.
“You want people to maximize the benefit they’ll get from the money they spend,” Marra says. “[Glucosamine and chondroitin] are safe, but they aren’t necessarily effective in clinical trials.”
At the end of the six-month-study, only 50 percent said they were feeling benefits from the pain medicine and natural supplements, far fewer than reported relief from non-drug interventions like exercise. Marra says this indicates that lifestyle changes may be more effective than medication alone.
“If they are overweight they should lose weight. That’s one of the more effective things to do. They should exercise and work with someone to find a plan that suits their needs and lifestyle. There are a lot of things they can do to self manage their disease and hopefully prevent future complications,” Marra says.
Marra says while people might have been engaging in good habits at the study’s end, it’s unclear how long that would continue since researchers only followed them for six months.
“Sadly I think these things are hard to sustain over time. I would suspect that these things aren’t as sustained as we would like them to be. So that would require more effort on behalf of the patients,” Marra says.
Dr. Jayanthi, of Loyola University, says he also has some questions about how recruitment for study participants was done.
“I would have loved to see how they diagnosed with nothing but a symptom survey. Because out of the people they talked to, 190 out of 194 had arthritis. I have X-rays and other things so I am a little skeptical about the recruitment and selection bias,” Dr. Jayanthi says.
He also says there is some inherent bias in the participants, which were mostly white woman. “I don’t want people to think that only white women and obese people get arthritis. That’s not necessarily the normal distribution of arthritis in our country,” Dr. Jayanthi says.
But he says it doesn’t surprise him that people took charge of their own treatment. He just hopes that somewhere down the road they reach out to a doctor or medical professional for support.
“The disease process doesn’t improve with time,” Dr. Jayanthi says. “At some point, it will be too much to handle on their own. So it’s important to remember to have a reliable relationship with a health-care provider.”